Epidemiological investigations and meta-analyses of predictive studies have consistently demonstrated the importance of psychosocial variables as postpartum depression risk factors. To address this, several psychosocial treatment strategies have been evaluated for the treatment of postpartum depression. The purpose of this paper is to determine the current state of scientific knowledge related to the treatment of postpartum depression from a psychosocial perspective. Thirteen trials were included in the review that evaluated the following interventions: peer support, partner support, non-directive counselling, home visits by mental health nurses, and collaborative models of care. Owing to methodological limitations of the included trials, the effectiveness of most psychosocial approaches for the treatment of postpartum depression is equivocal. Large, multisite randomised-controlled trials are needed to compare different treatment approaches, examine the effectiveness of individual treatment components, and determine which treatments are most useful for women with different risk factors or clinical presentations of postpartum depression.
Introduction
The cause of postpartum depression is multifactorial ; however, meta-analytic findings consistently highlight the importance of psychosocial variables, such as the lack of social support, marital conflict, and stressful life events. Analyses of social support variables in predictive studies clearly show a significant increase in the risk of postpartum depression in women who (1) do not have someone to talk openly with who has shared and understood a similar problem ; (2) lack an intimate confidant or friend ; (3) do not receive support without having to ask for it ; and (4) feel socially isolated . In addition, women who report marital difficulties have been found to be at risk of developing postpartum depression . Depressed mothers are more likely to be dissatisfied with the support received from their partners , feel communication is poor , perceive their partner as uncaring , report a decline in the affection and cohesion in their relationship , and find a discrepancy between their expectations and later experiences of closeness to their partner . Higher levels of postpartum depressive symptomatology have been linked to perceived stress during pregnancy , childcare stressors , and the number of stressful life events since delivery . To address this issue, a variety of psychosocial interventions with the aim of enhancing the availability or perception of support have been developed to treat postpartum depression . The purpose of this paper is to determine the current state of scientific knowledge related to the treatment of postpartum depression from a psychosocial perspective.
Theoretical underpinnings of psychosocial interventions
Social relationships and social support can affect mental health through several pathways. Members of a social network can exert a salutary influence on mental health by role modelling health-relevant behaviours . Integration in a social network might also directly produce positive psychological states, including sense of purpose, belonging, and recognition of self-worth . These positive states, in turn, might benefit mental health because of an increased motivation for self-care, as well as the modulation of the neuroendocrine response to stress . Being part of a social network enhances the likelihood of accessing various forms of social support, which in turn protects against distress . Social support may also act on several different points in the pathway between stressful life events and mental health. The perceived availability of social support in the face of a stressful event may lead to a more benign appraisal of the situation, thereby preventing a cascade of ensuing negative emotional and behavioural responses . Perceived or received support may either reduce the negative emotional reaction to a stressful event or dampen the physiologic, behavioural response to stress, or both . These findings are consistent with Thoits’s theoretical model of the mechanisms through which social ties affect physical and psychological wellbeing. According to Thoits, seven different psychosocial mechanisms link aspects of social relationships to physical and emotional well-being. The theorised seven mechanisms are as follows: social influence and social comparison; social control; role-based purpose and meaning (mattering); self-esteem; sense of control; belonging and companionship; and perceived support availability.
Thoits suggests that the effectiveness of social support as a stress buffer requires actually received or enacted support, and is based on specific combinations of source and type of support. Primary group members are individuals who have not had past personal experience with the health problem or stressor that the distressed person is currently facing (experientially dissimilar), and secondary group members are individuals who have experienced or are experiencing a similar stressor (experientially similar). Thoits hypothesises that emotional support (e.g. love, caring, and sympathy) and instrumental support are likely to be the most effective stress buffers when coming from significant others, whereas informational and appraisal support (e.g. validation of feelings, advice, and role modelling) are most helpful coming from similar others. The provision of emotional support is likely to be more effective coming from significant others given such group members’ lives are also disrupted by the stressor, and their attempts at providing informational support may be ineffective, as they are less likely to have direct experience. In comparison, secondary group members or similar others may be better sources of informational support, and they may be better able to provide empathy, role modelling, and coping assistance given their past or current experience.
Theoretical underpinnings of psychosocial interventions
Social relationships and social support can affect mental health through several pathways. Members of a social network can exert a salutary influence on mental health by role modelling health-relevant behaviours . Integration in a social network might also directly produce positive psychological states, including sense of purpose, belonging, and recognition of self-worth . These positive states, in turn, might benefit mental health because of an increased motivation for self-care, as well as the modulation of the neuroendocrine response to stress . Being part of a social network enhances the likelihood of accessing various forms of social support, which in turn protects against distress . Social support may also act on several different points in the pathway between stressful life events and mental health. The perceived availability of social support in the face of a stressful event may lead to a more benign appraisal of the situation, thereby preventing a cascade of ensuing negative emotional and behavioural responses . Perceived or received support may either reduce the negative emotional reaction to a stressful event or dampen the physiologic, behavioural response to stress, or both . These findings are consistent with Thoits’s theoretical model of the mechanisms through which social ties affect physical and psychological wellbeing. According to Thoits, seven different psychosocial mechanisms link aspects of social relationships to physical and emotional well-being. The theorised seven mechanisms are as follows: social influence and social comparison; social control; role-based purpose and meaning (mattering); self-esteem; sense of control; belonging and companionship; and perceived support availability.
Thoits suggests that the effectiveness of social support as a stress buffer requires actually received or enacted support, and is based on specific combinations of source and type of support. Primary group members are individuals who have not had past personal experience with the health problem or stressor that the distressed person is currently facing (experientially dissimilar), and secondary group members are individuals who have experienced or are experiencing a similar stressor (experientially similar). Thoits hypothesises that emotional support (e.g. love, caring, and sympathy) and instrumental support are likely to be the most effective stress buffers when coming from significant others, whereas informational and appraisal support (e.g. validation of feelings, advice, and role modelling) are most helpful coming from similar others. The provision of emotional support is likely to be more effective coming from significant others given such group members’ lives are also disrupted by the stressor, and their attempts at providing informational support may be ineffective, as they are less likely to have direct experience. In comparison, secondary group members or similar others may be better sources of informational support, and they may be better able to provide empathy, role modelling, and coping assistance given their past or current experience.
Psychosocial treatment interventions
Several psychosocial treatment strategies have been evaluated for the treatment of postpartum depression based on the importance of psychosocial variables and the theoretical premise that supportive relationships during the perinatal period could reduce depressive symptoms and enhance a mother’s feeling of wellbeing ( Table 1 ).
Study | Design | Participants | Intervention | Outcome measure | Results | Limitations |
---|---|---|---|---|---|---|
Peer support | ||||||
Fleming et al. | Quasi-experimental | 142 Canadian women recruited on postpartum wards to return screening instrument at 2 weeks; identified using CES-D and EPDS; I 1 = 44 mothers I 2 = 15 mothers C = 83 mothers | Two treatment groups: (1) eight weekly semi-structured group sessions lasting 2 h provided by two psychologists; (2) ‘group by mail’ where transcripts of the preceding support group were mailed to women. | Postpartum depression at 6 weeks and 5 months; CES-D | At 5 months, significant improvement occurred in maternal mood independent of group allocation. The supportive interventions did not modify maternal mood. Depressed mothers had more negative feelings towards themselves, their partners, and the motherhood role than non-depressed women. | Non-random group allocation; significant differences in group sizes; ‘depressed’ and ‘non-depressed’ women participated in all study groups; weak measure of postpartum depression. |
Chen et al. | RCT | 60 Chinese women recruited on postpartum wards to return screening instrument at 3 weeks; identified using BDI; I = 30 mothers C = 30 mothers | Four weekly semi-structured group sessions lasting 1.5–2 h, facilitated by a nurse. | Postpartum depression after treatment at 4 weeks; BDI | Significant decrease in BDI scores in women attending support group. At the 4-week assessment, 60% of women in the control group remained depressed compared with only 33% in the support group. | Only 44% of mothers returned screening questionnaire; inexplicit randomisation process; unstandardised intervention; data analysis was not intent-to-treat. |
Morgan et al. | Single group | 34 Australian women, including 20 partners; identified using EPDS. | Eight weekly 2-h group sessions and one couple session facilitated by a nurse and occupational therapist. | Postpartum depression after treatment at 8 weeks and at 12-months’ follow up; EPDS and GHQ. | Significant decrease in maternal scores before and after treatment; 22% of women scored over 12 on EPDS after treatment and no women had depressive symptoms at 12-week follow up. | Small sample size; atypical sample (74% had spent 1 week in a residential unit to help with mothering issues); lack of a control group; co-interventions, as 50% were receiving treatment by a health professional and ‘some’ were taking anti-depressant medication. |
Dennis | Pilot RCT; random allocation using sealed envelopes; intent-to-treat. | 42 Canadian women screened by public health nurses during immunisation clinic; identified using EPDS; I = 20 mothers C = 22 mothers | Telephone-based support from a mother recruited from the community who previously experienced postpartum depression and received a 4-h training session. | Postpartum depression at 4 and 8 weeks after randomisation; EPDS. | Significant group differences in probable major postpartum depression (EPDS >12) at all time periods. At the 4-week assessment, 40.9% of women in the control group scored over 12 on the EPDS compared with only 10% in the peer support group; similar findings at 8 weeks. | Small sample size. |
Letourneau et al. | RCT; random allocation using sealed envelopes. | 60 Canadian women with EPDS over 12 and healthy infant less than 9 months; I = 27 mothers C = 33 mothers | Home visits and telephone calls for 12 weeks by peers who were mothers that had recovered from postpartum depression for 2 years or more. | Postpartum depression at 6 and 12 weeks after randomisation; EPDS. | At 12 weeks, a significant difference was found in EPDS scores favouring the control group ( P = 0.04). | Significant group difference in baseline characteristics related to antidepressant use. |
Partner support | ||||||
Misri et al. | RCT | 29 Canadian women who met the DSM-IV criteria for major depressive disorder with postpartum onset; I = 16 mothers C = 13 mothers | Seven psycho-educational visits with a psychiatrist during which the mother’s partner participated in four of the seven sessions. | Postpartum depression after treatment and 4-week follow up; EPDS | Immediately after the intervention, no significant group differences were observed in mean EPDS scores ( P = 0.20). At the 4-week follow up, significant group differences in mean EPDS scores favouring the intervention group (M = 8.6, SD = 5.2 v M = 14.7, SD = 7.2, P = 0.013). | Small sample size; significant group difference in baseline characteristics related to their partners’ marriage appraisals; inexplicit randomisation process. |
Non-directive counselling | ||||||
Holden et al. | RCT; group allocation based on random numbers. | 50 UK women; community-based EPDS screening at 6 weeks with a second screening at 13 weeks using psychiatric interview; I = 26 mothers C = 24 mothers | Eight weekly counselling visits at home by health visitors trained in non-directive counselling. | Postpartum depression at 13 weeks after randomisation; EPDS and clinical interview. | Significant group differences. According to RDC criteria, 18 (69%) of the 26 depressed women in the counselled group had fully recovered compared with only nine (38%) of the 24 women in the control group. | Small sample size; 3 women in each group were considered to have taken anti-depressant medication at a therapeutic level. |
Wickberg and Hwang | RCT | 31 Swedish women; two-stage population-based screening at 8 and 12 weeks using EPDS; I = 15 mothers C = 16 mothers | Six weekly 1-h counselling visits at home by nurses trained in non-directive counselling. | Postpartum depression at 6 weeks after randomisation; modified MADRS. | Significant group differences. Twelve (80%) of 15 women with major depression in the study group were fully recovered after the intervention compared with four (25%) of 16 in the control group. | Small sample size; inexplicit randomisation process. |
Cooper et al. | RCT; group allocation based on drawing coloured balls. | 193 UK women screened with a mailed EPDS; identified using DSM-III-R criteria; I 1 = 43 mothers I 2 = 50 mothers I 3 = 48 mothers C = 52 mothers | Three treatments: (1) cognitive–behavioural therapy; (2) psychodynamic therapy; or (3) non-directive counselling provided weekly at home from 8 to 18 weeks postpartum. | Postpartum depression at 18, 36 and 72 weeks and 5 years’ follow up; EPDS and clinical interview. | Significant improvements in all three treatment groups. Mean EPDS score for the counselling group at 18 weeks was 9.9 (SD = 5.9) compared with 11.3 (SD = 4.8) for the control group ( P = 0.02); all group improvements were complete by 36 weeks. | 35% of women in the control group were experiencing high social adversity at baseline. |
Morrell et al. | Cluster RCT; computer randomisation; stratified by number of expected births per year; intent-to-treat. | 595 UK women; identified with mailed EPDS at 6 weeks postpartum; I = 404 mothers C = 191 mothers | Two treatments: (1) cognitive–behavioural therapy; or (2) person-centred therapy (non-directive) provided weekly at home for 8 weeks by trained health visitors. | Postpartum depression at 6, 12, and 18 months; EPDS, SF-12 mental component. | At 6 months, a significant effect was found for treatment on depression scores, but no significant group difference between the two approaches. For the subgroup of women with 6-week EPDS scores of 12 or higher, the mean EPDS score for the intervention group at 6 months was 9.2 (SD = 5.4) compared with 11.3 (SD = 5.8) for the control group; similar findings were found at 12 months. | High attrition at 12 and 18 months. |
Sharp et al. | RCT; computer randomisation; intent-to-treat. | 254 UK women who met ICD-10 criteria for major depression in the first 6 months postpartum; I 1 = 129 mothers I 2 = 125 mothers | Two treatments: (1) antidepressants or (2) non-directive counselling (listening visits) by trained health visitors, which commenced after 4 weeks. | Postpartum depression at 4 and 18 weeks after randomisation; EPDS | At the 4-week assessment, recovery rates based on EPDS scores (<13) significantly favoured the antidepressant group (45%) over the supportive care group (20%). At the 18-week follow up, again recovery favoured antidepressants (62% v 51%). | No true control group after 4 weeks; change in study protocol before completion; high number of women in both groups received both interventions. |
Home visits by mental health nurses | ||||||
Tamaki | RCT; random allocation by computer-generated numbers. | 18 Japanese women with diagnosis of major depression; two-stage screening at 4 and 8 weeks using EPDS and SCID; I = 9 mothers C = 9 mothers | 4 weekly home visits over 8 weeks by nurse or midwife trained to provide support | Postpartum depression at 1 and 6 weeks after treatment; EPDS and clinical interview. | At the 1-week assessment, 66.7% of women in the control group remained depressed compared with only 28.6% in the intervention group. A significant reduction in EPDS scores over time in the intervention group but not the control group. | Small sample size; data analysis was not intent-to-treat. |
Collaborative models of care | ||||||
Gjerdingen et al. | RCT; group allocation via computer-generated block sizes of 10; stratification by clinic. | 39 US women; identified using the SCID and PHQ-9; I = 19 mothers C = 20 mothers | Stepped collaborative care which included (1) referral to primary care provider for initial treatment; (2) regular telephone follow-up with care manager; (3) decision support for primary care providers; (4) consultation or referral to mental health specialist for special cases; and (5) patient education provided through primary physician, care manager, and mailed PPD brochure | Postpartum depression at 8, 12, 24 and 36 weeks; PHQ-9 and SF-36 mental health scale | No significant group differences related to Postpartum depression. | Small sample size; training in stepped care provided to all health providers (including those who gave usual care); 3 health providers gave care to women in both groups; lack of intent-to-treat. |
Yawn et al. | Cluster RCT | 28 practices were randomised; I = 14 practices C = 14 practices; 2343 women were enrolled between 5 and 12 weeks postpartum. | Practices received education and tools for PPD screening, diagnosis, initiation of treatment, and follow up within their practices. | Postpartum depression at 6 and 12 months; EPDS and PHQ-9 | Among the 654 women with elevated postpartum depression screening scores, those in the intervention practices were more likely to receive a diagnosis ( P = 0.0006) and treatment for postpartum depression ( P = 0.002). They also had lower depressive symptom levels at 6 ( P = 0.07) and 12 months ( P = 0.001) postpartum. | Significant group differences related to baseline characteristics; lack of intent-to-treat. |

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