Skip to main content

Advertisement

Table 1 Summary of the final list of the 15 studies for the treatment of PND and their characteristics

From: Cognitive-Behavioural therapy and interpersonal psychotherapy for the treatment of post-natal depression: a narrative review

Name of author(s) Setting – Location -dates Target Population Delivery mode Screening procedures Outcome measures Participants Control group Treatment group Nature of Intervention Intervention provider Experimental conditions Duration and number of sessions Measure/ timescale Follow up Summary of main outcomes Quality of study Reporting bias Limitations
[59] Ammerman et al. (2013 Adopted by [53] USA Treatment Postpartum Individual, home visits EPDS, SCID, MDD diagnosis, HDRS, BDI-II, GAF, OTTF SCID, HDRS, EPDS, BDI-II, GAF, OTTF, consumer satisfaction rating 93 46, control condition = home visits along with receiving treatment in the community 47 CBT related approach focused on stress management, goal setting, and problem solving Clinicians CBT vs routine primary care 15 h of contact 4.75, 7.75 months follow up Yes Overall positive outcome in favor of CBT versus typical care, “results found benefit at 4.5 and 7.5 months follow up” Fair = good information on demographic population, same instruments administered in pre-treatment, post-treatment and follow ups, Yes “Population exhibited mild to moderate depression and the findings of this study cannot be generalised to the whole of population, e.g. severe depression, psychosis, etc., reporting bias, small study size, limited screening instruments, short term follow up, overall positive outcome in favor of CBT versus typical care but results were not statistically significant”
[49] Appleby et al. (1997) Adopted by [48, 51, 53] South Manchester, England, May 1993-Feb 1995 Treatment “Urban, community sample”, postpartum Individual, home visits EPDS, HAM-D, “Revised Clinical Interview Schedule” “Revised Clinical Interview Schedule”-EPDS, HDRS 87 Not applicable as all four study groups received some kind of intervention 87 Placebo and 6 CBT sessions fortnightly - CBT focused on techniques such as challenging and modifying negative automatic thoughts and “dysfunctional beliefs”, increasing pleasant stimuli and reducing behaviours which could have a negative effect on mood Psychologist with no previous clinical experience Medication (Fluoxetine) and 1 CBT session, medication and 6 CBT sessions, Placebo and 1 CBT session, Placebo and 6 CBT sessions “6 biweekly CBT sessions” 1, 4, and 12 weeks post-treatment Yes “Immediately post-intervention, all 4 groups showed significant improvement on the Revised Clinical Interview Schedule, Fluoxetine, an anxiolytic antidepressant, is an effective treatment for PND, A course of six sessions of CBT is more effective than a single session, there seems to be no advantage in receiving both medication and counselling at the same time, the simplest treatment after a single session of CBT may be fluoxetine as it removes the need for additional counselling, Many women with PND are reluctant to take medication” “Fair as clinical interview was used but results of CBT effect is unclear as the use of medication is used in one of the groups, however they used independent assessors to evaluate study outcomes, not clear about allocation concealment” Unclear “30% attrition rates, exclusion of participants with chronic depression, combination of medication and CBT as the results were less successful in comparison to the use of medication itself”
[58] Bennett (2001) Adopted by [51] United Kingdom Treatment Women identified for “probable depression” Group EPDS EPDS 45 22, control condition = standard primary care with health visitor 23 Not manualised CBT, psychoeducation, relaxation techniques Health visitors 8 weekly two hour sessions Immediate and 24 weeks post-treatment Yes CBT has a good therapeutic effect on post-natal depression Not strong as there was small sample, limited use of instruments, “unclear if caregivers were blinded” Unclear “Small sample size”, it is demanding in terms of commitment on behalf of the participants, it is expensive and time consuming, high percentage of participants failing to “complete” treatment,
[50] Chabrol et al. (2002) Adopted y [48] Toulouse, and Narbonne, France Prevention/ Treatment Women identified with depressive symptoms Individual, home visits, clinic visits BDI, EPDS, HAM-D BDI, EPDS, HAM-D 48 30, control condition = routine care /clinic visits 18 “CBT with elements of psychoeducation, supportive and psychodynamic approach”, CBT focused on techniques such as challenging and modifying negative automatic thoughts and dysfunctional beliefs, increasing pleasant stimuli and reducing behaviours which could have a negative effect on mood “Master’s Degree level therapists” 5–8 home visits /6 weekly one hour sessions “Immediately post-intervention” No “Immediately post-intervention, women in the intervention group had reduced scores on all measures compared to women in the control group” Not strong as small sample, lack of follow up, no reporting of size of control and experimental groups in the review, however they “used manualised interventions and attempted to ensure adherence to the treatment protocol” Yes “Non-independent outcome assessment, small sample size, lack of follow-up”
[60] Cooper et al. (2003) Adopted by [48, 53] Participants homes, hospital settings-Cambridge, England, Jan 1990- Aug 1992 Treatment Women with post-partum depression, being primiparous, living close to maternity hospital, and English as their first language Individual, home visits EPDS Therapist Rating Scale, Kruskal-Wallis test, EPDS, DSM-III-R (SCID) 193 52, control conditions: routine primary care provided by the general practitioner and health visitors Counselling = 48, CBT = 42, Psychodynamic = 48 “Psychodynamic, non-directive counselling, and CBT which focused on issues in relation to the infant that the mothers would find difficult to cope with, and on issues in the mother’s relationship with the infant, mothers were given support through advice to manage difficulties, used problem-solving techniques, challenged thinking patterns” 6 in total where 3 experts in each one of the three treatments, and three non-specialists health visitors “Routine primary care, non-directive counselling, CBT, psychodynamic therapy” 10 weekly sessions of either CBT, psychodynamic, or non-directive counselling 4.5 months, 9 months, 18 months, 5 years post-partum Yes “All three interventions had better clinical outcomes than the control group, the psychodynamic group had a superior clinical effect in comparison to the other two treatments and to the control group on depression at 4.5 months post-partum, this changed subsequently at 9 months, 18 months and five years, where no real difference between control and intervention groups were reported” Good as they “ensured adherence to the clinical protocol” Yes “Not all specialists were familiar with home visiting but only the health visitors, thus some of the therapeutic outcomes in the groups of participants run by specialists, CBT and non-directive counselling were very low”
[62] Honey et al. (2002) Adopted by [53, 54] United Kingdom Treatment “Newly delivered mothers” Individual, home visits EPDS EPDS 45 22, control conditions = routine primary care administered by health visitors 23 “PEG, education, coping strategies, CBT techniques which focused on stress management, goal setting, and problem solving” Not reported CBT home visits vs routine care 8 × 2 hour weekly sessions 8 months follow up Yes Significant reduction in depression between intervention group and routine primary care Fair as they used a single self-report measure, short-term follow up, a combination of interventions used Yes “Population exhibited mild to moderate depression and the findings of this study cannot be generalised to the whole of population, e.g. severe depression, psychosis, etc., not enough information about population demographics except their age and mean, reporting bias, small sample size, small study size, limited screening instruments (only EPDS), short term follow up, overall positive outcome in favor of CBT versus typical care but results were not statistically significant, not clear what is the clinical effect of CBT as there is a mix of interventions”.
[63] Milgrom et al. (2005) Adopted by [53, 54] Australia Treatment “Newly delivered mothers-Postpartum” Group, individual, home visits BDI BDI 192 46, control conditions = care provided by health nurses C1 = 47, C2 = 66, C3 = 33 “C1 = CBT (coping with depression course), C2 = CBT-related,C3 = Group-based Cognitive-Behavioural Therapy including psychoeducation, role-playing, discussion, stress management, goal setting, and problem solving” Not reported Usual care 9 × 90 minute weekly sessions 3 months follow up Yes “Significant depression score reductions in all interventions in comparison to routine primary care” “Fair due to lack of generalisibility of results, small study size, lack of information, but adequate number of sessions and good information on the interventions themselves” Yes “Population exhibited mild to moderate depression and the findings of this study cannot be generalised to the whole of population, e.g. severe depression, psychosis, etc., not enough information about population demographics except their age and mean, reporting bias, small study size, limited screening instruments (only BDI), overall positive outcome in favor of CBT versus typical care but results were not statistically significant”
[65] Milgrom et al. (2011) Adopted by [53] Australia Treatment Postpartum Individual, public hospital, home visit, GP practice EPDS, BDI-II BDI-II 68 Not applicable GP management = 23, counselling + CBT delivered by nurse-22, counselling + CBT delivered by psychologist = 23 “CBT approach focused on stress management, goal setting, and problem solving” GPs, primary nurses, psychologists Management by trained GP vs. Counselling-CBT delivered by a trained nurses vs. Counselling-CBT delivered by a psychologist 3 h of contact 2 months follow up Yes All three interventions were effective for treating PND Not strong due to lack of control group, short term follow up, a mix of intervention providers were used Yes The size of sample was small, attrition rates were relatively high, no real control group, reports of medical practitioners instead of standardised interviews were used, single psychologist vs. multiple nurses, no long-term follow up, low referral ratio and treatment uptake, “results were not statistically significant”
[61] Misri (2004) Adopted by [51] Canada Treatment Postpartum women having been diagnosed with depression Individual HRSD, EPDS HRSD, EPDS 35 16, typical care = antidepressant medication in a hospital outpatient program 19 “CBT which was based on a treatment manual focused on challenging and modifying dysfunctional beliefs, and correcting the information processing of the individuals” Psychologist Weekly 1-h CBT sessions plus antidepressant medication vs standard care (antidepressant medication) 12 one hour sessions plus medication 12 weeks post-treatment Yes CBT has a good therapeutic effect on PND Not strong as “it provided data on anxiety”, “the timing of the final outcome assessment was immediately post-treatment”, “blinding of caregivers was not possible as they were involved in the intervention” Yes Small sample size, it is demanding in terms of commitment on behalf of the participants, it is expensive and time consuming, high percentage of participants failing to “complete” treatment, CBT is combined with medication, no reporting of size of control and experimental groups, however they “used manualised interventions and attempted to ensure adherence to the treatment protocol”
[55] Morrell (2006) Adopted by [51] United Kingdom Treatment Postpartum women identifying with depressive symptomatology through self-report measures Individual, home visits EPDS EPDS 595 191, control conditions = participants referred to general practitioners by health visitors 404 “CBT treatment focused on modifying dysfunctional beliefs, and correcting the information processing of the individuals” “Health visitors, nurses” A weekly basis for one hour up to a maximum of 8 weeks, CBT, and non-directive counselling vs. standard primary care 8 one-hour sessions 24, 52, and 72 weeks postpartum Yes “It compared psychological with psychosocial interventions” CBT has a good therapeutic effect on post-natal depression, non-directive counselling can also be effective in treating post-natal depressive symptomatology Not strong as big sample size but no information on the number of participants on control and experimental groups in the review, use of self-report measures Not clear It is demanding in terms of commitment on behalf of the participants, it is expensive and time consuming, high percentage of participants failing to “complete” treatment, high attrition rate at 24 weeks post-partum, no information on the number of participants on the control group and intervention group
[16] O’Hara (2000) Adopted by [51, 52] United States Treatment Women identified through a multi-stage community screening process for depression, “social adjustment, marital relations, and postpartum adjustment” Individual SCID, HRSD, BDI, PAQ, SASSR HRSD, BDI, PAQ, SASSR 120 51, control conditions = waiting list 48 Interpersonal psychotherapy using psychosocial and psychological components compared to a waiting list “Trained therapists” Interpersonal psychotherapy vs waiting list 12 h sessions over 12 weeks “4, 8, and 12 weeks post-randomisation” No “IPT is an efficacious treatment for postpartum depression. It reduced depressive symptoms and improved social adjustment, and represents an alternative to pharmacotherapy, particularly for women who are breastfeeding”, improvement on all questionnaires Fair as the sample size is descent, population is diagnosed with major depression, use of multiple instruments, use of trained therapists, but no follow up, positive results on mother-infant relationships do not reflect the relationship with the newborn baby Not clear No follow up so long-term effect of treatment is unknown, doesn’t measure the relationship between mother and newborn baby, not clear if the intervention was delivered at home or was clinically based
[57] Prendergast and Austin (2001) Adopted by [48, 51, 53] Australia Treatment Women identified with depression-“Community sample”-postpartum Individual DSM-IV, EPDS EPDS, MADRS 37 20, control conditions = “standard care with 6 weekly clinic visits lasting 20 to 60 min” 17 Home visits-“CBT sessions”, CBT focused on techniques such as challenging and modifying negative automatic thoughts and dysfunctional beliefs, increasing pleasant stimuli and reducing behaviours which could have a negative effect on mood “Early Childhood Nurses” CBT vs standard care (“weekly clinic visits”) “6 weekly CBT sessions” 10 weeks post-partum Yes No difference between the two groups post-intervention but better outcome for the intervention group six months follow up but not statistical significant Fair as “they followed participants over time” “used manualised interventions and attempted to ensure adherence to the treatment protocol” Not clear “Although the efficacy of the interventions has been demonstrated for some outcomes, effectiveness studies are required to establish whether such benefits would be obtained in routine practice”, 55% drop out rate for control group, small sample size, no “intention-to-treat analysis”
[56] Rahman (2008) Adopted by [47] Pakistan Treatment Pregnant women, who were married, between 16 and 45 years old, and had depression Individual DSM-IV clinical interview, HDRS DSM-IV clinical interview, HDRS 903 (105 lost in follow up) 440 (54 lost in follow up), control conditions = routine care with regular weekly visits in the last month before birth, and monthly visits after that by health workers 463 (51 lost in follow up) Home based CBT intervention which was part of a community health program called “Thinking Healthy”, CBT approach used pictures and structured activities for achieving specific everyday goals “Community health workers” “Enhanced care involving home visits” vs. usual care 16 sessions in 11 months, 1.5 sessions per month 6 and 12 months postnatally Yes “Non-mental health professional can deliver positive psychosocial interventions with good therapeutic outcomes in middle-income countries” Fair as this study examined antenatal and post-natal depression and the timing of the intervention was delivered in two stages, in the third trimester of pregnancy and ten months postnatally, adequate info on attrition rates of population in the “final analysis”, “information on follow up was adequate” Yes, “low risk of bias on blinding of participants and personnel, and of outcome assessment, and no selective reporting” “Highlights stigma of depression on mothers and unrealistic to expect mothers would be supported to participate in studies as such, resource demanding in resource limited countries due to the use of professionals over a lengthy period of time, disadvantaged over preventive treatments, also disadvantaged due to individual delivery vs. Group based”, “unable to carry out a subgroup analysis of treatment versus preventive interventions because only one treatment intervention was identified”, “CBT was part of psychosocial management of post-natal depression and included elements such as psychosocial improvement, helping the individual to consider a general sense of wellbeing”
[64] Rojas (2007) Adopted by [54] Chile Treatment Newly delivered and low income mothers Groups EPDS EPDS 230 116, usual care = GP consult with antidepressant medication, and referral to specialty services if needed 114 CBT focused on psychoeducation Trained doctors, midwives, nurses Group CBT vs. usual care 8 × 50 minute weekly sessions 3 month and six month follow up Yes “Mothers with newborn babies and on low income can benefit from multi-component medication, bigger improvement in three months than six months” Fair, good sample size but only use of self-report measure, not very long follow up, Yes Unclear around the “purity” of CBT intervention (“multi-component intervention”), combination of CBT with psychoeducation and pharmacology, EPDS is not a diagnostic tool, unclear of the reason(s) the initial therapeutic effect of three months to six months post-intervention was reduced
[66] Wiklund et al. (2010) Adopted by [53] Sweden Treatment Postpartum - mothers with signs of depression Individual, maternity clinic EPDS EPDS 67 34, standard care = a single session with a midwife or obstetrician focusing on debrief 33 CBT approach focused on “stress management, goal setting, and problem solving” Midwives CBT vs standard care 21 h of contact 2.75 months follow up Yes “Brief CBT is effective in treating women with signs of depression” Fair as small sample size and use of self-report measure, sufficient time of intervention allocation, short-term follow up Yes “Population had not been diagnosed with post-natal depression, and thus findings of this study cannot be generalised, not enough information about population demographics, reporting bias, small study size, limited screening instruments (only EPDS), short term follow up, results not statistically significant, not certain on long-term effectiveness of CBT, lack of clinical diagnostic procedure”
  1. *all sentences in “quotes” are an exact copy of the original statement from the authors, and all abbreviations are included after the limitations section