By Will Boggs MD
NEW YORK—Pregnant and postpartum women who are at increased risk of perinatal depression should be referred for counseling to prevent perinatal depression, according to a new recommendation from the US Preventive Services Task Force (USPSTF).
"Counseling can help those who are at increased risk of developing perinatal depression by preventing perinatal depression before it starts or reducing the severity of depressive symptoms," Dr. Aaron B. Caughey, Task Force member from Oregon Health and Science University, Portland, Oregon, told Reuters Health by email. "This can improve quality of life for the mother, as well as the health and wellbeing of the baby."
As many as 1 in 7 women experience perinatal depression, one of the leading complications of pregnancy and the postpartum period. Perinatal depression can result in adverse short-term and long-term effects on both mother and child, so preventing it is an important public health objective.
After reviewing the available evidence on a variety of interventions that aim to prevent perinatal depression, USPSTF concluded with moderate certainty that counseling interventions, such as cognitive behavioral therapy and interpersonal therapy, are moderately effective in preventing perinatal depression in those at increased risk.
"The Task Force found that we do not yet have enough evidence on non-counseling interventions, including physical activity, education, medications, dietary supplements, and health systems interventions, and we need more research to know if these interventions can help prevent perinatal depression," Dr. Caughey said. "Dietary supplements, such as selenium and vitamin D, have shown promise, but more research is needed in this area as well."
"Physicians should be talking with all of their patients about their health history and home situation, so that they can identify people who are pregnant or have had a baby in the past year and might be at increased risk for perinatal depression," he said. "Then the physician can let these patients know that they might be at risk for depression, and that there are services available that have been proven to help prevent it from developing. If the patient is interested, they can then be provided with or referred to counseling."
The USPSTF recommendation is based on an evidence report and systematic review conducted by Dr. Elizabeth O'Connor from Kaiser Permanente's Center for Health Research, Portland, Oregon and colleagues. Dr. O'Connor told Reuters Health by email, "I was surprised (and heartened) at the extent of the research in this area. Fifty studies met our inclusion criteria, which is quite a large body of literature. And, it was heartening that a couple of the counseling interventions have been tested in multiple studies, since we know that it is quite common for single study results to not hold up on replication. Our confidence in an intervention's results really grows when we see a continued success upon replication and can start to understand the contexts or populations where they work well and may not work as well."
"There are interventions that can help prevent perinatal depression," she said. "Preventive educational counseling is probably a new concept for a lot of people. I think most people view mental health interventions as talk therapy, but these were more about education, helping pregnant persons find support and resources, and being aware of their personal vulnerabilities."
"These are all things that most counselors are well-equipped to do, as are other allied health practitioners, so I really think these are interventions that could be made widely available," Dr. O'Connor said. "I hope that as health systems begin implementing the recommendation, they will work with researchers or program evaluation specialists to study the impact of the interventions and refine them for their setting and population in a planned and thoughtful way, and that they will publish what they learn so others can also benefit from their experience."
In a related editorial, Dr. Marlene P. Freeman from Massachusetts General Hospital, Boston, addressed the challenges of implementing these recommendations. She told Reuters health by email, "Access to mental health care in general remains a major challenge in many this country. It will be critical for multiple stakeholders, including health care providers across disciplines, advocacy groups, and other stakeholders, to work together on how to make sure that women who are identified as 'at risk' receive appropriate referrals and are able to access care."
"Also, it will be important to make sure that there is longitudinal follow-up in place to make sure that women who experience perinatal psychiatric disorders despite efforts to prevent them receive appropriate care in a timely manner," she said. "In addition, it will be important to determine what strategies work best for different groups of women." [email interview]
"If the aims of the recommendations can be achieved, there may be tremendous benefits to women and their children," Dr. Freeman said. "However, there are major challenges to the implementation of these recommendations. One is that screening for women at risk for perinatal depression is more difficult than screening for acute perinatal depression. To date, we lack easy to use tools to do so in clinical settings. While there are a number of known risk factors for perinatal depression that affect large numbers of reproductive aged women, there are no simple routine screening mechanisms in place to determine who would most benefit from preventative treatments."
Another editorial by Dr. Jennifer N. Felder from University of California, San Francisco, San Francisco, California discussed opportunities and challenges of implementing the USPSTF recommendations. She told Reuters Health by email, "I expect that the biggest obstacle to implementing the USPSTF recommendations will be inadequate infrastructure to support the clinical pathway from identifying who is at risk to providing treatment. Fortunately, we can draw from analogous efforts to increase screening and treatment of acute depression during the perinatal period, such as the MCPAP for Moms program in Massachusetts. This program provides consultation, resources, and referrals to help physicians manage depression among perinatal women."
"Physicians do not need to wait until a woman is experiencing acute depression to intervene," she said. "The most widely studied preventive interventions are cognitive behavior therapy and interpersonal psychotherapy. These have been studied primarily among perinatal women with histories of depression or elevated depressive symptoms. Therefore, physicians may want to prioritize screening for these risk factors."
Dr. Felder added, "There are online resources for finding local therapists with relevant expertise (http://bit.ly/2I9Fpsw and http://bit.ly/2I9FIUc). "
In a third editorial, Dr. Katherine L. Wisner and colleagues from Northwestern University Feinberg School of Medicine, Chicago, describe a number of health system approaches that might prevent perinatal depression: the Reach Out, Stay Strong, Essentials (ROSE) interpersonal psychotherapy-derived program; home visiting programs, such as Healthy Families America and the Nurse-Family Partnership; and collaborative care and statewide provider support programs.
Also underway, they note, is the Optimizing Medication Management for Mothers with Depression (OPTI-MOM) study, supported by the National Institute of Child and Health Development, which was designed to define optimal antidepressant dosing to prevent recurrence through the childbearing period.
In a fourth editorial, Dr. Lyndsay A. Avalos and colleagues from Kaiser Permanente Northern California's Division of Research, Oakland, California consider several challenges to implementing the USPSTF recommendations. Dr. Avalos and co-author Dr. Tracy Flanagan told Reuters Health by email, "There are two main obstacles. The first is the lack of a screening tool or scoring system to identify women at risk of perinatal depression. The second is recognizing that successful referral of all women presenting with an increased risk of perinatal depression would put enormous pressure on existing mental health resources that are already suffering from a shortage of mental health providers."
"The significant number of women at risk for or suffering with perinatal depression with little or no access to health care highlights the need for evidence-based research on interventions that are not resource intensive that community safety net health systems and community organizations could either support or develop," they said.
"The new recommendation highlights a key and important shift from identification and treatment of perinatal depression to prevention," they concluded. "Prevention is a key factor for improving the health of our communities, and specifically the health of mothers and their children. Given the current limited mental health resources, we need to invest in evidence-based interventions, such as mindfulness programs, mobile health interventions, or peer-based programs, to assess their effectiveness in reducing the risk of perinatal depression for women at risk."
Dr. Darius Tandon, associate professor of Medical Social Sciences and codirector of the Center for Community Health, Northwestern University Fienberg School of Medicine, who was not involved in the other publications, told Reuters Health by email, "Many women who are not accessing prenatal care may be accessing services elsewhere during the perinatal period, including home visiting programs and Women, Infant, and Children (WIC) clinics. These settings should also be identifying women at risk for developing postpartum depression and, ideally, integrating evidence-based interventions, such as those highlighted in the USPSTF report, into their core services."
"There also needs to be greater attention placed on developing viable reimbursement mechanisms through Medicaid for preventive services; currently, the Medicaid system is better designed to provide reimbursement for postpartum depression screening and treatment," he said.
Dr. Tandon added, "Rather than feeling like they must bear the full burden for addressing their clients' mental health needs, physicians should consider working with service providers, such as home visiting programs and other community-based agencies, who may be able to provide necessary mental health supports and services to women that physicians identify as being at risk for developing postpartum depression."
The USPSTF recommendation statement, evidence report, and related editorials appear in the February 12th issue of JAMA.
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