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Gambling: The Hidden Addiction
Robert Ladouceur
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In Review
The Road Less Travelled: Moving From Distribution to Determinants in the Study of Gambling Epidemiology
Howard J Shaffer, Richard A LaBrie, Debi A LaPlante, Sarah E Nelson, Michael V Stanton
(PDF)

Assessing and Treating Problem Gambling: Empirical Status and Promising Trends
Tony Toneatto, Goldie Millar
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Review Paper Preventing Postpartum Depression Part II: A Critical Review of Nonbiological Interventions
Cindy-Lee E Dennis
(PDF)

Continuity of Care in Mental Health Services: Toward Clarifying the Construct
Anthony S Joyce, T Cameron Wild, Carol E Adair, Gerald M McDougall, Alan Gordon, Norman Costigan, Anora Beckie, Laura Kowalsky, Gloria Pasmeny, Fran Barnes
(PDF)

The Boundary Between Borderline Personality Disorder and Bipolar Disorder: Current Concepts and Challenges
Chandra A Magill
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Selective Serotonin Reuptake Inhibitor and Venlafaxine Use in Children and Adolescents With Major Depressive Disorder: A Systematic Review of Published Randomized Controlled Trials
Darren B Courtney
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Original Research Twenty-Year Course of Schizophrenia: The Madras Longitudinal Study
R Thara
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Book Reviews
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Evidence and Experience in Psychiatry. Volume 6. Eating Disorders
Review by
Hany Bissada

Integrated Treatment for Mood and Substance Use Disorders
Review by
Nady el-Guebaly

Letters to the Editor
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Attention-Deficit Hyperactivity Disorder in a Sample of Omani Schoolboys

Effective Use of Olanzapine for Obsessive–Compulsive Symptoms in a Patient With Bipolar Disorder

Monoamine Oxidase Inhibitors and Subarachnoid Hemorrhage

Beyond Haloperidol: Teaching Emergency Medicine Residents to Manage Acute Agitation and Aggression in the Emergency Department
Hypothalamic–Pituitary–Adrenal Function and Preventing Major Depressive Episodes

A Romanian Adoptee’s Journey From Latency Age to Adolescence

Stéatose hépatique non alcoolique secondaire à la clozapine

Re: A Case–Control Study on Psychological Symptoms in Sleep Apnea-Hypopnea Syndrome (SAHS)

Reply: A Case–Control Study on Psychological Symptoms in Sleep Apnea-Hypopnea Syndrome (SAHS)

Review Paper

Preventing Postpartum Depression Part II: A Critical Review of Nonbiological Interventions

Cindy-Lee E Dennis, RN, PhD¹

Approximately 13% of women from diverse cultures will experience postpartum depression (PPD) within the first 12 weeks after childbirth (1). This hidden morbidity has well-documented health consequences for the mother, child, and family. While women who have suffered from PPD are twice as likely to experience future episodes of depression over a 5-year period (2), infants and children are particularly vulnerable. PPD can cause impaired maternal–infant interactions (3) and negative perceptions of infant behaviour (4), which have been linked to attachment insecurity (5,6), emotional developmental delay (5,7), and social or interaction difficulties (8,9). Infants aged as young as 3 months have been shown to ably detect their mother’s mood and to modify their own responses accordingly (10). While cognitive skills (11), expressive language development (12), and attention (13) have been negatively influenced by PPD, it has also been reported that children of mothers with depression are 2 to 5 times more likely to develop long-term behavioural problems (14,15). Child neglect and (or) abuse (16) and marital stress resulting in separation or divorce (17,18) are other reported outcomes. Maternal and infant mortality are rare but real consequences of PPD.

Because of the potentially devastating and long-standing effects depression can have on the mother, her children, and the mother–child relationship, preventing PPD is an important public health approach. Further, increased contact with health professionals during the perinatal period provides an ideal opportunity for preventive interventions. This paper critically reviews the literature to determine the current state of scientific knowledge concerning the prevention of PPD from a nonbiological perspective.

Method

Search Strategy
Databases searched for this review include Medline, PubMed, Cinahl, PsycINFO, Embase, ProQuest, the Cochrane Library, and the World Health Organization Reproductive Health Library. As part of the quality assessment process and to measure the capture rate of relevant references, tables of contents of key journals were hand-searched for the past 2 years, graduate thesis abstracts were scanned, reference lists of included studies and relevant reviews were examined, and several PPD researchers were contacted via e-mail. In total, approximately 100 abstracts were examined for inclusion suitability.

Inclusion and Exclusion Criteria
The literature review systematically searched for peer-reviewed English-language articles published between January 1, 1966, and December 31, 2003. Only research studies that focused on PPD (that is, inception of depression within the first year postpartum) were reviewed. Finally, research studies evaluating preventive interventions must have incorporated a PPD outcome assessment beyond the first week postpartum.

Methodology for Synthesis
Studies included were evaluated according to the published criteria used by the Canadian Task Force on Preventive Health Care (19) and were given research design and quality (that is, internal validity) ratings (Table 1). After the quality of evidence assessment was complete, each preventive approach was classified to determine clinical practice recommendations, according to the following grading scheme: A = there is good evidence to recommend this approach; B = there is fair evidence to recommend this approach; C = the evidence is conflicting and does not allow making a recommendation for or against use of this approach, though other factors may influence decision making; D = there is fair evidence to recommend against this approach; E = there is good evidence to recommend against this approach; I = there is insufficient evidence (in quantity and [or] quality) to make a recommendation, though other factors may influence decision making.

Interpersonal Psychotherapy (Table 2)
Two studies were found that evaluated the principles of interpersonal psychotherapy (IPT). In a US trial, 37 pregnant women were randomly assigned to receive either treatment-as-usual (n = 19) or a group intervention (4 weekly group sessions; n = 18) (20). Most of the women in the intervention group (n = 15, 88%) attended 3 of the 4 sessions, and 35 participants completed both the Beck Depression Inventory (BDI) pre- and postintervention and the Structured Clinical Interview for DSM-III–R (SCID) at 12 weeks postpartum. Six (33%) out of 18 women in the control group developed PPD, compared with none of the 17 women in the intervention group.

In a similar study, 45 pregnant US women with at least 1 PPD risk factor (for example, current or past history of depression) were randomly allocated to either an intervention group (consisting of 5 individual IPT sessions; n = 24) or a control group (consisting of standard care; n = 21) (21). At 4 weeks postpartum, significantly more mothers in the control group met DSM-III-R criteria for major depression than in the intervention group (25% vs 0%, P = 0.02). However, the prophylactic effects were not maintained through 24 weeks postpartum, as 3 (15%) mothers in the intervention group vs 4 (23.5%) mothers in the control group suffered from postpartum depression (P = 0.40).

Cognitive-Behavioural Therapy (Table 2)
Only 2 studies have evaluated cognitive-behavioural therapy (CBT). In a Finnish trial, 176 pregnant women with a severe fear of childbirth were randomly allocated at 26 weeks gestation to either CBT therapy (n = 85) or conventional therapy (n = 91) (22). While birth-related concerns decreased in the CBT group, no significant group differences in BDI scores were found at 12 weeks postpartum.

In a French study, the effect of CBT targeting both the prevention and treatment of PPD was evaluated (23); only the preventive component will be described here. Pregnant women were screened during an obstetric clinic and at-risk women (that is, those with an Edinburgh Postnatal Depression Scale [EPDS] score > 8) were alternately allocated to either a control group (consisting of usual care; n = 128) or an intervention group (consisting of 1 individualized CBT session; n = 113). At 4 to 6 weeks postpartum, 29/97 (29.8%) mothers in the intervention group vs 55/114 (48.2%) mothers in the control group scored over 11 on the EPDS (c² = 7.36, P = 0.007).

Psychological Debriefing
In a UK trial, 120 inhospital primiparous women were randomized to receive either usual care (n = 60) or a midwife-led debriefing session before hospital discharge (n = 60) (24). Of the 114 women who returned the Hospital Anxiety and Depression Scale (HADS), mailed at 3 weeks postpartum, significantly fewer mothers in the intervention group (n = 5; 8.6%) exhibited depressive symptomatology, compared with the control group (n =31; 53.4%). Conversely, in a larger and well-executed Australian trial involving 1041 women who had operative deliveries, inhospital midwife-led debriefing had a negative effect (25). In particular, more women allocated to the debriefing group exhibited depressive symptomatology (n = 81, 17%) at 24 weeks postpartum, compared with women allocated to usual postpartum care (n = 65, 14%), though the difference was not significant (odds ratio [OR] 1.24; 95%CI, 0.87 to 1.77). The possibility that this intervention contributed to emotional health problems for some women cannot be excluded.

In another Australian trial stratified for parity and delivery mode, 1745 women were randomly allocated to receive either a standardized debriefing session within 72 hours of delivery (n = 875) or usual care (n = 870) (26). There were no significant differences between control and intervention groups in EPDS scores at 2, 6, or 12 months postpartum or in proportions of women who met diagnostic criteria for major or minor depression during the postpartum year (intervention group, 17.8% vs control group, 18.2%; relative risk 0.99; 95%CI, 0.87 to 1.11). There were also no differences in median time to onset of depression (intervention group, 6 weeks [range 4 to 9 weeks] vs control group, 4 weeks [range 3 to 8 weeks]; P = 0.84), or in duration of depression (intervention group, 24 weeks [range 12 to 46 weeks] vs control group, 22 weeks [range 10 to 52 weeks]; P = 0.98). Though there was a high prevalence of depression among women during the first year after childbirth, a session of midwife-led debriefing was not effective in preventing PPD.

Finally, to study whether proactive educational counselling in addition to routine clinical care reduces psychological morbidity, a trial was conducted with Chinese women who had unexpected antenatal, intrapartum, or postpartum events leading to suboptimal outcomes during pregnancy and childbirth (27). Based on the HADS, the General Health Questionnaire (GHQ), and the Clinical Global Impression (CGI), which were completed before and after counselling at 6 weeks and 6 months postdelivery, no significant group differences were found in psychological morbidity. In particular, 26 (9.8%) women in the intervention group and 35 (14%) in the control group met the criteria of “possible case” of PPD, which was identified using a cut-off score of 4/5 in the GHQ.

Psychosocial Interventions

Antenatal and Postnatal Classes (Table 3)
In a pioneering study, Gordon and Gordon conducted a quasi-experimental study to evaluate the effect of antenatal classes on the prevention of postpartum emotional problems (28). In the study, 161 pregnant US women were allocated to either standard antenatal classes (n = 76) or standard antenatal classes plus 2 additional sessions (n = 85). Obstetricians assessed “emotional problems,” using a 4-point scale at 6 to 8 weeks postpartum. Only 15% of mothers in the intervention group experienced emotional problems, compared with 37% of mothers in the control group (c² = 7.3; P < 0.01). Only one-half the participants completed the 24-week follow-up, during which 1/46 (2%) mothers in the intervention group vs 10/36 (28%) mothers in the control group were experiencing emotional problems (c² = 9; P < 0.01). Though this study has many limitations, it provided the basis for the antenatal class interventions described below.

In an Australian trial, 144 high-risk pregnant women, identified using a modified antenatal screening questionnaire, were randomized to receive either 3 midwife-led group sessions (n = 73) or standard antenatal care (n = 71) (29). The response rate for the mailed EPDS questionnaire was 92% at 6 and 12 weeks postpartum and 87% at 24 weeks postpartum. At 6, 12, and 24 weeks postpartum, the proportion of mothers in the intervention and control groups with EPDS scores above 12 was not significantly different, which indicates that the intervention did not reduce PPD.

In a similar trial, which incorporated the screening of 1300 UK women, 209 high-risk women were randomized to evaluate the effect of a structured “risk factor–reducing” program designed specifically to increase social support and problem-solving skills (30). The intervention (n = 103) comprised 6 structured 2-hour weekly antenatal classes and 1 postpartum class and was compared with routine antenatal care (n = 106). Incorporating diverse depressive measures, the follow-up rate exceeded 90%. The proportion of women with an EPDS score above 10 did not differ significantly between the 2 groups.

In another UK study, a more intensive intervention incorporating 11 monthly meetings was conducted (31). Women expecting their first or second child and who were designated as “more vulnerable” were allocated to either the Surviving Parenthood preventive intervention group (n = 47) or a control group (n = 52), according to the expected delivery date. Significant differences in EPDS scores at 12 weeks postpartum were found among primiparous women, but not among multiparous women. The mean EPDS score for primiparous women in the intervention group was 3.0, SD 2.50, compared with 8.0, SD 4.53, in the control group (P = 0.005). For multiparous women, no significant group differences were found; the intervention group’s mean score was 6.5, SD 6.10, compared with the control group’s score of 9.0, SD 6.60. Notably, in all 3 preceding trials, the low group attendance rate was a significant limitation.

In a pilot trial, primiparous Australian women between 12 and 24 weeks’ gestation were screened, using a researcher-developed risk-factor scale (32). At-risk women were randomly allocated to receive either standard antenatal classes (n = 21) or intervention classes (n = 23) consisting of 10 structured sessions. Participants completed questionnaires at 6 and 24 weeks postpartum; 16 (70%) mothers in the intervention group and 12 (57%) mothers in the control group completed the questionnaire administered at 24 weeks. No significant group differences in depressive symptomatology were found. Mean EPDS scores at 6 and 24 weeks postpartum for mothers in the intervention group were 7.40 and 7.57, compared with 9.06 and 8.09 for mothers in the control group (P > 0.05).

Intrapartum Support (Table 3)
A considerable number of women experience labour without continuous support. Because labour is frequently viewed as a high-risk situation necessitating interventions and imposed restrictions, it has been suggested that the clinical environment of childbirth may have an adverse effect on psychological outcomes. To test this hypothesis, 2 trials have been conducted that evaluate the effect of doula support (that is, support provided by an experienced lay woman). In a South African trial, 189 women labouring alone were randomly allocated to receive either additional companionship (n = 92) or usual care (n = 97) (33). At 6 weeks postpartum, the Pitt Depression Inventory was completed during a postpartum visit; 40 mothers (21%) were lost to follow-up. Mothers in the intervention group had lower mean depression scores (mean score 10.4) than did mothers in the control group (mean score 23.3) (P < 0.001). This study was continued with an additional 73 enrolled women, and the EPDS was administered at 1 year postpartum (34); only 50% of mothers completed this questionnaire. No significant group differences were found (intervention group mean 11, SD 5.31, vs control group mean 11, SD 0.60, P = 0.78). In a larger US trial involving 3 health maintenance organization–managed hospitals, nulliparous women were randomized to receive either usual care (n = 165) or support from a doula (n = 149) (35). Data were obtained from phone interviews conducted at 4 to 6 weeks postpartum, and the results showed no significant group differences in mean PPD scores.

To evaluate the effectiveness of professional labour support, a well-designed, randomized controlled trial (RCT) with prognostic stratification by centre and parity was conducted (36). Thirteen Canadian and US hospitals randomized 6915 women to receive either usual care (n = 3461) or continuous labour support by a specially trained nurse (n = 3454). The primary outcome measure was caesarean delivery rate, but maternal mood at 6 to 8 weeks postpartum was also included as an outcome measure. Of the 81% of participants who returned the follow-up questionnaire, 245 (8.7%) women in the labour support group had EPDS scores > 12, compared with 277 (10.1%) women in the usual care group (P = 0.08).

Supportive Interactions (Table 4)
Five trials have been conducted to evaluate the preventive effect of diverse supportive interventions. An Australian trial that targeted families where the child was at greater risk for poor health and developmental outcomes for environmental reasons (n = 181) evaluated the effect of extensive nursing home visits on PPD at 6 and 16 weeks postpartum (37,38). Women were recruited in the immediate postpartum period, according to self-reported vulnerability factors, and were randomly allocated to receive either a structured program of nursing home visits (n = 90) or standard community child health services (control group; n = 91). Mothers in the intervention group had lower EPDS scores (only 5.8% scored > 12 on the EPDS) at 6 weeks postpartum than did mothers in the control group (20.7% scored >12 on the EPDS). At the 16-week follow-up, 160 families were available for assessment, and the earlier difference in EPDS scores was not maintained.

Recognizing a current trend in health care, and perinatal care in particular, a recent UK trial evaluated the effect of lay support in addition to usual postpartum care provided by midwives (39). Mothers were randomly allocated to receive either usual care (n = 312) or additional support provided by trained community postnatal support workers (n = 311). At 6 weeks postpartum, there was a significant difference in EPDS scores, favouring the control group (intervention group mean 7.4, SD 5.2; control group mean 6.7, SD 5.5; P = 0.05). There was no difference at 24 weeks (intervention group mean 6.6, SD 5.1; control group mean 6.7, SD 5.6; P = 0.73).

Finally, a trial with a 2 x 2 factorial design was conducted to evaluate 2 interventions: first, an invitation to a weekly postpartum support group; and second, a mailed postpartum support manual (40). A total of 1004 primiparous Scottish women were recruited ( a total of 753 mothers in the 2 different intervention groups and 251 mothers in the control group), with 83% finishing the baseline questionnaire and 71% completing the 24-week follow-up. There were no significant differences in EPDS scores between the control and intervention groups at 12 and 24 weeks, either in the proportion scoring above 11 on the EPDS or in mean EPDS scores.

Quality Improvement Interventions

Continuity of Care (Table 4)
According to policy-makers’ suggestions that continuity of care may increase women’s satisfaction, new models have been proffered. To compare midwife-managed care with shared care (for example, care divided among midwives, hospital physicians, and general practitioners [GPs]), a trial of 1299 pregnant women with no adverse characteristics at booking was conducted (consent rate 82%); PPD was a psychosocial outcome with 60% of participants returning questionnaires at 7 weeks postpartum (41). Women in the midwife-managed group (n = 648) had significantly lower EPDS scores (mean score 8.1, SD 4.9), compared with mothers in the shared care group (n = 651) (mean score 9.0, SD 4.9; t = –2.6; 95%CI, –1.6 to –0.2; P = 0.01). However, nonsignificant group differences were found in EPDS scores above 12 (midwife-managed group, 71/426 [16.7%] vs shared care group, 84/362 [23.2%]).

The effect of team midwifery was further evaluated in Australia, where low-risk women in early pregnancy were randomly allocated to receive either team midwifery care (n = 495) or standard care (n = 505) (42). Physicians attended most women in standard care where caregiver continuity was lacking. According to mailed questionnaires at 8 weeks postpartum, no significant group differences were found in depressive symptomatology: 16% of women in the midwifery care group exhibited EPDS scores above 12, compared with 12% in the standard care group (P = 0.19).

To evaluate the effectiveness of continuous midwifery care in reducing rates of PPD among women with a history of depression, 51 women from a sample of 98 pregnant women were randomly allocated at antenatal booking to continuous midwifery care. The remaining 47 women received standard maternity care (43). In total, 87 women (44 from the intervention group and 43 control subjects) completed baseline assessments after randomization and outcome assessments at 12 weeks postpartum. In pregnancy, 49% of women had an episode of major or minor depression according to DSM-III-R criteria, 26% developed a new episode of illness after antenatal booking, and 23% suffered depression in the first 12 weeks postpartum. There were no differences between groups regarding total depression rates, rates of antenatal depression, depression that occurred postbooking, postpartum depression, or duration of depressive episodes. While continuous midwifery care did not prevent PPD, it was highly successful at engaging women in treatment.

Antenatal Identification and Notification (Table 4)
Identifying PPD is often problematic because women frequently fail to report symptoms to their family physician or public health nurse. Also, health professionals may fail to ask appropriate questions that could assist diagnosis in the postpartum period. While several attempts have been made to identify at-risk women to evaluate antenatal interventions aimed at preventing PPD, these studies have been largely unsuccessful. This is partly because of researchers’ targeting antenatal classes, where poor attendance is common. One possible way to address this issue is to include any intervention as part of individualized antenatal care. To test this hypothesis, an RCT was conducted with Australian women attending their first prenatal visit who were screened for PPD risk factors (44). The intervention consisted of 1) a booklet about PPD, which included contact numbers; 2) prenatal screening, using the EPDS; 3) a discussion with each identified woman about her risk of developing PPD; and 4) a letter to each woman’s referring GP and local child health nurse, alerting them to the woman’s risk for PPD. Of the 509 women who were sent a follow-up questionnaire at 16 weeks postpartum, 371 (72.9%) responded. While 26% of women reported an EPDS score >12, there was no significant difference among EPDS scores between the intervention (46/192, 24%) and control groups (50/177, 28.2%; OR 0.80; 95%CI, 0.50 to 1.28). This study is consistent with other research findings suggesting that efforts to prevent PPD by implementing interventions in the antenatal period are unsuccessful.

Early Postpartum Follow-Up (Table 5)
Traditionally, women have been advised to attend a 6-week postpartum check-up with their primary health care provider. However, some researchers have hypothesized that postpartum care initiated earlier may either prevent or allow for the early identification and management of problems, including PPD. For example, in a US quasi-experimental study, the effect of early-initiated support by the mother’s and the neonate’s future primary care provider (such as a pediatrician or nurse practitioner) was evaluated (45). Mother–neonate pairs were allocated to either a control group (consisting of routine postpartum care with a first clinic visit at 2 weeks postpartum; n = 122) or an intervention group (consisting of early postpartum communication; n = 129). All participants were interviewed at 8 weeks postpartum. Mothers in the intervention group had Center for Epidemiological Study of Depression Scale (CES-D) scores (mean 11.54) similar to those of mothers in the control group (mean 13.65) (P = 0.11), with 29% of mothers in the intervention group scoring above 16, compared with 39% of mothers in the control group (P = 0.18).

In Australia, a trial incorporating 683 mothers was conducted to investigate whether an earlier postpartum checkup with a GP decreased depressive symptomatology and other negative health outcomes (46). All participants received a letter and appointment date to visit a GP for checkup. The intervention group received a date for 1 week after hospital discharge and the control group received a date for 6 weeks postpartum. According to postal questionnaires, the percentage of women scoring above 12 on the EPDS at 12 weeks postpartum (intervention group, 16.6% vs control group, 13.6%; c² = 0.8, P = 0.37) or 24 weeks postpartum (intervention group, 11.6% vs control group, 12.8%; c² = 0.2, P = 0.69) did not differ significantly between the 2 groups.

Flexible Postpartum Care (Table 5)
In a well-designed cluster RCT that assessed community postpartum care and was redesigned to identify and manage individual needs, 36 UK GP practices were randomly allocated to either an intervention group (n = 17) or a control group (n = 19) (47). Of the 2064 participating women, 1087 (53%) were in practices randomly assigned to the intervention group (consisting of extended midwifery care with no routine contact with GPs and incorporating the use of a symptom checklist and the EPDS), and 977 (47%) were in practices assigned to the control group (consisting of 7 midwifery home visits 10 to 14 days postpartum, care from health visitors thereafter, with GPs completing routine home visits, and a final 6- to 8-week checkup). In total, 801/1087 (77%) women in the intervention group and 702/977 (76%) mothers in the control group returned the 16-week postal questionnaire. Significant group differences were found: 14.4% of mothers in the intervention group scored above 12 on the EPDS, compared with 21.3% of mothers in the control group (P = 0.01). The numerous study strengths indicate that redesigning care to be flexible and tailored to individual needs may help to improve women’s mental health outcomes.

Other Interventions

Educational Strategies (Table 5)
Frequent contact with health professionals during pregnancy presents an ideal situation for providing information. A trial was conducted in Australia to determine the effect of antenatal education on the prevention of PPD (48). A total of 206 primiparous women 28 to 36 weeks gestation were randomized to either a control group (receiving usual antenatal care; n = 103) or an intervention group (receiving diverse educational materials; n = 103). Researchers assessed depressive symptomatology, using the Profile of Mood States (POMS) questionnaire. The questionnaire was administered once antenatally and twice postnatally, once between 8 and 12 weeks, and once between 16 and 24 weeks. A total of 188 mothers completed the study protocol. No significant group difference was found on the depression subscale: mean scores for both the intervention and control groups ranged from 4.0 to 5.0 at all time periods (P > 0.05). While this trial suggests that antenatal education may not prevent PPD, a small descriptive Japanese study (n = 40) found that an antenatal class provided by a psychiatrist and midwife as part of an obstetric psychiatric liaison service that includes PPD information and availability of postpartum resources may decrease the severity of PPD and the time between onset of depressive symptoms and seeking professional help (49).

The preventive effect of additional information in the postpartum period was also examined. In a quasi-experimental study, 500 Taiwanese women were screened at 4 weeks postpartum; those with an EPDS score above 10 were considered to be at risk for PPD and eligible to participate in the study (50). A total of 70 women were allocated to either the experimental group (wherein a 3-page booklet was provided at 6 weeks postpartum; n = 35) or a control group (wherein the group received standard postpartum care; n = 35). While EPDS scores in both groups decreased significantly at 12 weeks postpartum, 24 (68.6%) mothers in the control group continued to have an EPDS score $10, compared with only 14 (40%) mothers who received the informational booklet.

Relaxation With Guided Imagery (Table 5)
To determine the effect of relaxation with guided imagery on anxiety, depression, and self-esteem, 60 primiparous US women were recruited from a postpartum unit and randomly allocated to either a control group (receiving 15 minutes daily of tape-recorded music for 4 weeks; n = 30) or an intervention group (receiving 15 minutes daily of tape-recorded relaxation with guided-imagery protocol for 4 weeks; n = 30) (51). As measured by the CES-D, mothers in the intervention group (mean 1.37, SD 0.32) had less depressive symptomatology at 4 weeks postpartum than did mothers in the control group (mean 1.64, SD 0.53; t = –2.35, P = 0.01).

Discussion

The long-term consequences of PPD suggest preventive approaches are warranted. Manipulation of different risk factors may increase the associated likelihood of developing PPD in several different ways. The most obvious strategy is to decrease the amount of exposure to a given risk factor or, alternatively, to reduce the strength or mechanism of the relation between the risk factor and PPD (52). However, translating risk-factor research into predictive screening protocols and preventive interventions has met with limited success, as complex interactions of biopsychosocial risk factors with individual variations need to be contemplated.

Twenty-nine studies were examined in this review, with the diverse etiology of PPD reflected in the broad range of approaches considered, including interpersonal psychotherapy, cognitive-behavioural therapy, psychological debriefing, antenatal classes, intrapartum support, supportive interactions, continuity of care, antenatal identification and notification, early postpartum follow-up, flexible postpartum care, educational strategies, and relaxation with guided imagery. Although theoretical justifications for many of these approaches have been presented, there is insufficient evidence to unequivocally recommend any particular intervention (Table 6). This is partly owing to methodological limitations, such as poor research design or inadequate sample size, but it is also a result of insufficient evidence demonstrating intervention efficacy. Despite the recent upsurge of interest in this area, many questions remain unanswered, which has several implications for research.