Perinatal Depression: Preventive Interventions

Perinatal depression, which is the occurrence of a depressive disorder during pregnancy or following childbirth, affects as many as 1 in 6 pregnancies and is one of the most common complications of pregnancy and the postpartum period.¹ In 2022, the Centers for Disease Control and Prevention (CDC) reported that among women with live births, the prevalence of self-reported depression during pregnancy was 16.8%, with 12.7% of women self-reporting postpartum depressive symptoms. There are noted disparities in the rates of perinatal depression. The highest rates of perinatal depression are found in those younger than age 19 years (22.2%), American Indian/Alaska Native women (22.0%), those with less than 12 years of education (17.8%), and unmarried women (16.9%).^1,2

It is well established that perinatal depression can result in negative short- and long-term effects on both the woman and child. Women with perinatal depression can experience disengagement from their infants and are more likely to exhibit lower levels of positive maternal behaviors, such as praising and playing with their child.^3,4 Perinatal depression increases the risk of maternal suicide and suicidal ideation. While acts of harming the fetus and newborn are rare, mothers with depression report more thoughts of harming their infants than mothers without depression.^3,5,6 Perinatal depression is linked to an increased risk of preterm birth, small for gestational age newborns, and low birth weight.⁴ Infants whose mothers have perinatal depression are at increased risk of early cessation of breastfeeding and have been shown to receive fewer preventive health services compared with infants whose mothers are without depressive symptoms.⁷

There are a variety of effective interventions available to treat perinatal depression once it is diagnosed. Many of these same interventions have been proposed as a method to prevent perinatal depression when provided during pregnancy or in the immediate postpartum period.

The USPSTF concludes with moderate certainty that counseling interventions to prevent perinatal depression have a moderate net benefit for those at increased risk.

See Table 1 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.⁸

Patient Population Under Consideration

This recommendation applies to adolescents and adults who are pregnant or who are less than 1 year postpartum. It does not apply to those who have a current diagnosis of or are being treated for depression.

Definitions

Perinatal depression is the occurrence of a depressive disorder during pregnancy or following childbirth. Symptoms include loss of interest and energy, depressed mood, fluctuations in sleep or eating patterns, reduced ability to think or concentrate, feelings of worthlessness, and recurrent suicidal ideation.^9,10 Symptoms of depressed mood or loss of interest are required and must be present for a minimum of 2 weeks.¹¹ The diagnosis should not be confused with the less severe postpartum “baby blues,” which is a commonly experienced transient mood disturbance consisting of crying, irritability, fatigue, and anxiety that usually resolves within 10 to 14 days of delivery.^10,12

Assessment of Risk

Clinical risk factors that may be associated with the development of perinatal depression include a personal or family history of depression, a history of physical or sexual abuse, having an unplanned or unintended pregnancy, current stressful life events, a history of type I or type II diabetes or gestational diabetes, and complications during pregnancy (e.g., preterm delivery or pregnancy loss). Social factors such as low socioeconomic status, lack of social or financial support, and adolescent parenthood have also been shown to increase the risk of developing perinatal depression.²

There is no accurate screening tool for identifying all women at risk of perinatal depression and who might benefit from preventive interventions.² However, studies included in the systematic review suggested that counseling interventions are effective in women with one or more of the following: a history of depression, current depressive symptoms (that do not reach a diagnostic threshold), certain socioeconomic risk factors such as low income or adolescent or single parenthood, recent intimate partner violence, or mental health–related factors such as elevated anxiety symptoms or a history of significant negative life events.

Interventions

Studies on counseling interventions to prevent perinatal depression mainly included cognitive behavioral therapy and interpersonal therapy.² Cognitive behavioral therapy 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.¹³ Common therapeutic techniques include patient education, goal-setting, interventions to identify and modify maladaptive thought patterns, and behavioral activation. Interpersonal therapy focuses on treating interpersonal issues thought to contribute to the development or maintenance of psychological disorders. Common therapeutic techniques include using exploratory questions (i.e., open-ended and clarifying questions), role-playing, decision analysis, and communication analysis.¹⁴ The interventions reviewed by the USPSTF varied in setting, timing, intensity, format, and type of clinician performing the intervention. Counseling intervention trials mostly included populations considered to be at increased risk of perinatal depression.²

The USPSTF reviewed the evidence for several other interventions, including increased physical activity, education on the prenatal and postpartum periods, techniques for promoting infant sleep, prophylactic pharmacotherapy, complementary and alternative medicine, and supportive interventions such as home visits, general postpartum education, and case management. Physical activity and education interventions had encouraging findings; however, the USPSTF determined more evidence was needed to assess the benefits and harms of these interventions with greater certainty. In general, physical activity interventions were more intensive and of longer duration than general advice for exercise during and after pregnancy. For example, physical activity interventions in the evidence review lasted as long as 30 weeks and involved up to 90 contacts with a health counselor.¹⁵ Many were in a group format, and some provided additional behavior change support. Examples of education interventions included information on topics such as managing perinatal depression, parenting and infant-mother attachment, infant sleeping patterns and arrangements, and stress management techniques. For both of these interventions, there were a small number of studies, and the interventions varied considerably in format, delivery, number of contacts, and timing, making it difficult to develop a clear recommendation for pregnant and postpartum women.² The USPSTF is calling for more research on physical activity and education interventions. For more detail about these and other interventions, see the “Supporting Evidence” section.

Implementation

There are no data on the ideal timing for offering or referring to counseling interventions; however, most studies initiated interventions during the second or third trimester of pregnancy.² Ongoing assessment of risks that develop in pregnancy and the immediate postpartum period would be reasonable, and referral could occur at any time.

Counseling sessions reviewed for this recommendation ranged from one to 12 meetings lasting 4 to 70 weeks. The counseling format consisted mainly of group and individual sessions, mostly involving in-person visits. Intervention staff included mental health professionals (e.g., psychologists, licensed social workers, and psychiatrists), midwives, nurses, and health educators.²

Additional Tools and Resources

The Substance Abuse and Mental Health Administration’s Center for Excellence for Integrated Health Solutions (https://www.thenationalcouncil.org/program/center-of-excellence/) promotes the development of and provides resources for integrating primary and behavioral health services.¹⁶ The Substance Abuse and Mental Health Administration also provides resources for locating mental health services (https://findtreatment.gov/).¹⁷ The Mothers and Babies program, which is based on cognitive behavioral therapy, also provides web-based resources for families and clinicians (https://www.mothersandbabiesprogram.org/).¹⁸

Other Related USPSTF Recommendations

The USPSTF has a related recommendation on screening for depression in adults, including those who are pregnant and postpartum (B recommendation).¹⁹ The USPSTF also recommends screening for depression in adolescents ages 12 to 18 years (B recommendation) and found insufficient evidence to recommend for or against screening in children age 11 years or younger (I statement).²⁰

When final, this recommendation will update the 2019 recommendation statement on interventions to prevent perinatal depression. The current draft recommendation is consistent with the 2019 recommendation; both are B recommendations.²¹

Scope of Review

The USPSTF commissioned an update of its 2019 systematic evidence review to evaluate the evidence on the benefits and harms of preventive interventions for perinatal depression in pregnant or postpartum women or their children.² The review focused on studies of interventions involving those who were pregnant or new mothers at any age, who were both unselected and selected based on known risk factors. The review included studies of women with mental health symptoms, although studies focused on women with a depression diagnosis, women with high levels of depressive symptoms, or women currently being treated for a depressive disorder were excluded, as were studies of women with psychotic or developmental disorders. Interventions reviewed included counseling, physical activity, education, supportive interventions, and other behavioral interventions such as infant sleep training and debriefing sessions. Pharmacological approaches included the use of nortriptyline, sertraline, and ketamine. The main reported outcomes were depression status (measured as prevalence, incidence, and/or diagnosis based on clinical interview or scoring above a cutoff on a symptom severity scale) and continuous depression symptom scale scores. Other health outcomes reported and reviewed included measures of quality of life, anxiety, healthcare utilization, and infant or child outcomes.²

Benefits of Counseling Intervention

Twenty-seven (n=6,583) good- or fair-quality studies reported on counseling interventions.² Most were conducted in the United States (14/27) and were limited to adults (older than age 18 years) (21/27), and nearly all initiated interventions during pregnancy (26/27). Most of the trials (21/27) were limited to women considered to be at increased risk of perinatal depression because of depression history or symptoms, or non-depression–related risk factors such as low socioeconomic status, recent intimate partner violence, or young age. Most interventions (21/27) used cognitive behavioral or interpersonal therapy approaches. Counseling interventions lasted from as few as 4 weeks to as many as 70 weeks and from one to 12 sessions. The interventions consisted of both group (9/27) or individual (6/27) sessions, with some (12/27) involving both formats. Most interventions took place in person, although some included phone or video components. Across all counseling interventions, participants attended one-half to three-quarters of sessions.²

When the outcomes of incidence or prevalence, based on clinical interviews or on scoring above a cutoff on a symptom severity scale (e.g., Edinburgh Postnatal Depression Scale), were combined, counseling interventions were associated with a 17% reduction in the likelihood of perinatal depression (pooled relative risk [RR], 0.83 [95% CI, 0.72 to 0.95]; 21 studies; n=4,974; I²=0.0). When analyzing the effect of counseling interventions by study population, trials that selected women at increased risk of perinatal depression (based on symptoms, history of depression, or social or socioeconomic risk factors) demonstrated a statistically significant larger positive effect compared with trials enrolling lower-risk, unselected populations (31% vs. 5% risk reduction, respectively).

Twenty trials (n=2,880) reported continuous symptom score measures. Counseling interventions were associated with a small beneficial effect in symptom scores (standardized mean difference [SMD], -0.35 [95% CI, -0.57 to -0.12]; I²=84%) at the longest follow-up, ranging from 26 weeks gestation to 52 weeks postpartum. This change corresponds to an average 1.5-point greater reduction in depression symptom severity (on a 30-point Edinburgh Postnatal Depression Scale) compared with control groups. Trials reported other maternal or child outcomes such as anxiety, quality of life, and stress; however, most trials did not demonstrate statistically significant findings.²

Physical activity interventions to prevent perinatal depression were studied in seven trials (n=1,826). Pooled results from six trials (n=1,574) demonstrated that exercise interventions were associated with a 52% lower risk of depression at the longest followup period of 43 weeks postpartum (RR, 0.48 [95% CI, 0.345 to 0.66]; I²=0%). Pooled results from three trials (n=364) found a statistically significant difference in the SMD in depression symptom scores (SMD, -0.46 [95% CI, -0.80 to -0.12]; I²=0%) at the longest followup period (43 weeks). However, there were several limitations to this evidence.² There were relatively few studies, and most were assessed to have a moderate risk of bias. Moreover, the format, timing, number of contacts, and clinician providing the intervention varied. One common component was a group setting. However, it is unclear if social contact with other participants, rather than exercise itself, was responsible for the observed benefit. Finally, all but one of the studies were done outside the United States. These limitations lowered the USPSTF’s certainty on the potential benefits of this intervention.²

Twelve trials (n=11,415) reported educational interventions designed to prevent perinatal depression. Most participants were at a lower-than-average risk for perinatal depression. These were a highly heterogeneous set of interventions, and there was considerable variation in content, duration, intensity, and timing. Pooled analysis from seven trials showed a 21% reduction (RR, 0.79 [[95% CI, 0.70 to 0.88]]; I²=0%) in depression status. However, when examining the effect on depression symptoms, there was no difference between intervention and control groups.²

The USPSTF reviewed found limited evidence on other interventions, including infant sleep training, debriefing, complementary, and pharmacologic interventions, making it difficult to determine their effectiveness.²

Harms of Counseling Interventions

In general, harms were sparsely reported across the included intervention trials. Of the behavioral interventions, three counseling trials and one supportive intervention trial reported harms, finding no statistically significant differences between treatment groups. The three trials of prophylactic psychotropic pharmacologic intervention reported no serious harms. No other intervention trials reported on harms.²

See Table 2 for research needs and gaps related to interventions to prevent perinatal depression.

The USPSTF found no other guidelines on the prevention of perinatal depression. The American College of Obstetricians and Gynecologists recommends early postpartum followup care, including screening for depression and anxiety, for all postpartum women.²²

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2. Interventions to Prevent Perinatal Depression: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 248. Rockville, MD: Agency for Healthcare Research and Quality; 2025. AHRQ publication 25-05322-EF-1.
3. Slomian J, Honvo G, Emonts P, Reginster JY, Bruyère O. Consequences of maternal postpartum depression: a systematic review of maternal and infant outcomes. Womens Health (Lond). 2019;15:1745506519844044.
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5. Sit D, Luther J, Buysse D, et al. Suicidal ideation in depressed postpartum women: associations with childhood trauma, sleep disturbance and anxiety. J Psychiatr Res. 2015;66-67:95-104.
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7. Minkovitz CS, Strobino D, Scharfstein D, et al. Maternal depressive symptoms and children's receipt of health care in the first 3 years of life. Pediatrics. 2005;115(2):306-314.
8. U.S. Preventive Services Task Force. Procedure Manual. Accessed January 17, 2025. https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual
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11. American Psychological Association. Diagnostic and Statistical Manual for Psychiatric Disorders. 5th ed. Washington, DC: American Psychological Association; 2013.
12. American College of Obstetricians and Gynecologists. FAQs: Postpartum Depression. Accessed January 17, 2025. https://www.acog.org/womens-health/faqs/postpartum-depression
13. Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res. 2012;36(5):427-440.
14. Phipps MG, Raker CA, Ware CF, Zlotnick C. Randomized controlled trial to prevent postpartum depression in adolescent mothers. Am J Obstet Gynecol. 2013;208(3):192.e1-6.
15. Perales M, Refoyo I, Coteron J, Bacchi M, Barakat R. Exercise during pregnancy attenuates prenatal depression: a randomized controlled trial. Eval Health Prof. 2015;38(1):59-72.
16. Substance Abuse and Mental Health Administration. Center for Excellence for Integrated Health Solutions (CIHS). Accessed January 17, 2025. https://www.samhsa.gov/resource/tta/center-excellence-integrated-health-solutions-cihs
17. Substance Abuse and Mental Health Administration. FindTreatment.gov. https://findtreatment.samhsa.gov/
18. Mothers & Babies. Accessed January 17, 2025. http://www.mothersandbabiesprogram.org/.
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20. US Preventive Services Task Force. Screening for depression and suicide risk in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2022;328(15):1534-1542
21. US Preventive Services Task Force. Interventions to prevent perinatal depression: US Preventive Services Task Force recommendation statement. JAMA. 2019;321(6):580-587.
22. ACOG Committee Opinion No. 757: screening for perinatal depression. Obstet Gynecol. 2018;132(5):e208-e212.

Abbreviation: USPSTF=U.S. Preventive Services Task Force.

To fulfill its mission to improve health by making evidence-based recommendations for preventive services, the USPSTF routinely highlights the most critical evidence gaps for making actionable preventive services recommendations. For each evidence gap below, research should focus on settings similar to those in the United States to assist in generalizability to a U.S primary care population.

This table summarizes the key bodies of evidence needed for the USPSTF to make a recommendation for interventions to prevent perinatal depression.

Abbreviation: USPSTF=U.S. Preventive Services Task Force.