Cognitive behavioral therapy is identified as the most effective intervention for preventing postpartum depression based on evidence from multiple studies. CBT has been shown to significantly reduce depressive symptoms and decrease the risk of depressive episodes occurring through randomized controlled trials and meta-analyses. While CBT can be delivered in various ways, individual therapy in the postpartum period tends to be most effective. Further research is still needed to explore additional prevention interventions for reducing the burden of postpartum depression.

1. The Most Effective Intervention for the Prevention of Postpartum Depression
Leah McNulty
Cohort 2
December 6, 2015
Foundation Research/ Professor Narendorf

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Abstract
Postpartum depression is a serious problem that many researchers have attempted to treat.
It disturbs the relationships of the mother to both her infant and family; it is also detrimental for
the mother’s health. In this literature review, I examine studies that seek the best intervention for
the prevention of postpartum depression. I selected a total of 8 peer-reviewed journal articles that
consisted of studies pertaining to prevention. I found that cognitive-behavioral therapy is an
intervention that is successful, flexible, and has high research support. Other promising
interventions include antidepressants, hormone therapy, and peer-based phone support. I
conclude that more research is needed on interventions that can be used to prevent postpartum
depression in addition to treating it.
Introduction
Having a baby is a monumental life experience that includes a great deal of stress and
change. Anywhere from 50-80% of women who have babies suffer from what is known as
postpartum blues in the first two weeks after delivery. This can consist of having mood swings,
experiencing anxiety or feeling down, and being more emotional than usual (Johnson, 2011).
Postpartum blues goes away on its own for most women, but for 13%, it turns into what is
known as postpartum depression, or PPD. Symptoms of postpartum depression can include
things like “excessive guilt, anxiety, anhedonia, depressed mood, insomnia/hypertension,
suicidal ideation, and fatigue” (Johnson, 2011). PPD is more serious than postpartum blues and
for some women, it does not go away on its own (Johnson, 2011).
The focus of this literature review is postpartum depression. Research has shown that
PPD can disrupt the vital attachment process of a newborn to his or her mother. When women
are struggling with symptoms such as insomnia, guilt, or suicidal thoughts, it’s difficult to create

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and nurture the secure relationship that is needed for healthy development in a newborn child.
These children may also have an increased risk of poor health and abnormal functioning later in
life (Lefkovics, Baji, & Rigó, 2014). Therefore, PPD not only affects the woman who has it, but
also her child and family (Howard, et al., 2005).
EBP Question
Many studies have been done on the treatment of postpartum depression. Relatively few
studies, however, have been done on possible interventions that can prevent postpartum
depression altogether. It is my belief that if a successful intervention were found that could
prevent PPD, it would significantly reduce the disruption of the attachment processes with
women and their newborns. Therefore, my research question is “what is the most effective
intervention for the prevention of postpartum depression in adult women?”
Methods
I began with the database PsychINFO in my search for evidence pertaining to
interventions with PPD. My search terms were as follows: “postpartum depression or postnatal
depression or post natal depression AND prevention AND intervention.” These terms yielded
256 results. I then narrowed my search to peer-reviewed journal articles and had 192 results.
After this, I looked through many of the articles and excluded any pilot studies, intervention
protocols, treatment-only studies, specific population studies, and studies that included teenagers.
I also excluded many studies that were inconclusive, had weak designs, or were highly
ineffective. This left me with 5 articles that included a systematic review, a meta analysis, a
multisite randomized control trial, a randomized trial, and a short critical review. I then searched
the Cochrane Library for other articles that would assist me in finding interventions for the
prevention of PPD. My search terms were as follows: “postpartum depression or postnatal

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depression or post natal depression” in Article Titles “AND prevention AND intervention” in All
Fields. This yielded 140 results. I then limited my search to peer-reviewed journal articles
published between 2005 and 2015, narrowing my results to 103 articles. As with PsychINFO, I
excluded any pilot studies, intervention protocols, treatment-only studies, specific population
studies, and studies that included teenagers. I also excluded other articles that were weak in study
design or results. I selected 3 systematic reviews from this search that I used in my research for
this review.
Description of Chosen Approach
I chose cognitive-behavioral therapy for the most effective intervention for the prevention
of PPD. Cognitive-behavioral therapy, also known as CBT, is a type of psychotherapy that
focuses on targeting cognition to fix dysfunctional or unwanted behaviors and thoughts (Sockol,
2015). It is built on the Cognitive Model of Emotional Response, or the idea that one’s thoughts
are what creates his or her feelings and actions (NACBT, 2014). Mindfulness-Based Cognitive
Therapy and Problem-Solving Therapy are two therapies within the CBT field that have been
used with the prevention of postpartum depression. CBT can vary a great deal in how it is given,
how long it is given for, and where it is given (Sockol, 2015). The average amount of sessions is
normally around 16, and CBT involves some sort of homework, or work that the client will do in
between sessions to practice (NACBT, 2014). The meta analyses used to support this
intervention include studies that used CBT in a number of ways. Some general guidelines for
more effective practices of CBT were discovered in Sockol’s systematic review and meta
analysis. CBT is found to be more effective when given in the postpartum period rather than
during pregnancy. This is possibly because women, especially those who are not yet mothers,
find it difficult to place themselves in situations they may be in after their child is born. It is only

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when they are experiencing the postpartum period that they are able to utilize the CBT
effectively (Sockol, 2015). It is also found to be more effective when given individually rather
than in a group setting. It can also be adapted to different cultures and settings (Sockol, 2015).
Summary of Evidence and Rationale
The strongest research article I found in my search is a systematic review that contains a
meta analysis. This systematic review assess CBT only and its role in preventing and treating
PPD; it includes 40 different CBT trials, 14 of which are prevention studies with the average
sample size being n=192. Two analyses were done using the prevention studies in this review.
The first assesses change in depressive symptoms and uses 8 out of the 14 studies. Four studies
were found to have significant reduction in symptoms compared with the control group. The Q
Statistic for these studies showed high heterogeneity among the effect sizes. The overall effect
size for this analysis was 0.39; this particular effect size is in the small to medium range. As
stated in the previous section, the review found that effect size was not influenced by things like
the study design, type of control group or prevention, inclusion or exclusion of those with
depressive symptoms at the start, outcome measures, intervention, or location. Things like timing
of the assessment, quality of the study, gestation, and relationship status did, however, influence
effect size. The earlier the assessment or the stronger the study was, the less the symptoms were
reduced. Women later in their pregnancy or who were not cohabitating or married had their
symptoms reduced more.
The second analysis within the prevention analyses assesses how often depressive
episodes occur and includes 12 out of the 14 preventative studies. Three of those studies had
significantly less depressive episodes that occurred. The overall effect size is 0.64; the Q Statistic
for these studies does not have high heterogeneity. Similar to the first analysis, the effect size

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was not influenced by control or prevention type, assessment or outcome measures, inclusion or
exclusion of those with depressive symptoms at the start, intervention, location, or partner-
inclusion. It was also unaffected by assessment timing, number of sessions, or study quality.
Timing of the intervention and to whom the intervention was given did, however, influence the
effect size. Interventions that were given during pregnancy had less of a decrease in risk of
depressive episodes. Interventions that were given to individuals rather than groups showed more
of a decrease in risk of depressive episodes (Sockol, 2015).
Another meta-analysis that assesses only preventative interventions includes 10 different
CBT studies. The researchers analyze both depressive symptoms and occurrence of depressive
episodes at 6 months postpartum. The Hedge’s g score for CBT in relation to a decrease in
depressive symptoms is 0.23 and is based on 5 studies. It has a 95% CI score of 0-0.46, which is
in the broad range. The OR for CBT in relation to a decrease in depressive episodes is 0.63 and
is based on 8 studies. It has a 95% CI score of 0.41-0.97; it is broad as well (Sockol, Epperson, &
Barber, 2013). This analysis uses studies that test a number of different interventions from
education to therapy to social support. The authors conclude that based on these findings, the
specific intervention is not relevant to the success of reducing symptoms or depressive episodes.
They hypothesize that many of these interventions fulfill a woman’s lack of social support, a risk
factor for PPD, and thereby reduce negative symptoms. More research is needed, however
(Sockol, Epperson, & Barber, 2013).
Based on the detail and strength of the research above, CBT is an extremely successful
intervention in the prevention of PPD. It is not only effective but also flexible. Adult women who
are either pregnant or in their postpartum period experience many constraints on mobility due to
health, lack of childcare, and many other reasons. It is not easy for them to go out to a

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psychologist’s office, hospital, or group session (Sockol, 2015). CBT can be given anywhere,
even at home. CBT sessions on the internet have shown promise as well. According to Sockol,
almost 75% of homes in the United States have a computer, and with the rise of smartphones,
one in three houses in the world have internet access (2015). CBT can also be modified to
specifically fit a cultural group; sessions can highlight different cultural values about family,
motherhood, and other relevant topics to the postpartum period (Sockol, 2015). With the proven
success of CBT and these final practical reasons, I am confident that it is currently the most
effective intervention for the prevention of PPD.
Other Interventions Considered
Another intervention that I researched is exercise as it pertains to the postpartum period.
The study I reviewed is a randomized trial set up to test a theory-based physical activity
intervention to see if it is effective in preventing postpartum depression. 66 women were
assigned to the intervention and 64 women were assigned to a wellness/support contact control
group. Both the intervention and the contact control conditions were delivered by phone over a
period of six months. At the end of six months, 8% of women in each group were found to meet
depressive criteria based on the SCID-I, but less depressive symptoms were reported by the
intervention group based on the PHQ-9 (Lewis, et al., 2014). This study has a low validity for
two main reasons. Firstly, there is no true control group, and the wellness group’s exercise
during this time period was equivalent to the physical activity group’s exercise. Secondly, the
intervention itself may not have been administered equally. Therefore, this study is inconclusive
(Lewis, et al., 2014). Although physical exercise may help prevent PPD, I did not select it as a
promising treatment.

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The use of antidepressants in women with risk factors for PPD has also been researched
but is not the first choice for either researchers or women. A systematic review of two trials
involving 73 women tested Nortriptyline and Sertraline. While Nortriptyline has no effect,
Sertraline seems to reduce the recurrence of a depressive episode in women who had experienced
PPD previously (Howard, et al., 2005). Based on the studies’ lack of participants and intent-to-
treat analysis however, the researchers conclude that there is insufficient and unclear evidence
supporting that antidepressants given postpartum can prevent depression (Howard, et al., 2005).
Women are also hesitant to use antidepressants, especially while breastfeeding. Side-effects
could harm the child or affect the mother negatively (da Silva Magalhaes & Pinheiro, 2015).
Antidepressants may work in some cases, but do not appear to be the best choice for prevention.
Another pharmacological intervention I researched is hormone therapy. This is based off
the idea that PPD is caused by a woman’s hormones being out of balance due to the pregnancy
and delivery. A systematic review including two studies (n=229) found that synthetic progestin
is actually detrimental to women at this stage. It may have caused symptoms of PPD in some
women in this study. Natural progesterone has not been tested. In addition, oestrogen was tested
and found to be helpful in treatment of women with severe depression when compared with the
placebo, but it is inconclusive in terms of prevention (Dennis, Ross, & Herxheimer, 2008). This
approach was not chosen based on lack of research, but I personally believe it has merit.
A last intervention that was strongly considered is a peer-based phone intervention. In my
research, I found a multisite randomized control trial of this intervention (n=701). This same trial
was also included in a meta-analysis of psychological and psychosocial interventions that I came
across in my research. This therapy was given through telephone by mothers that had
experienced PPD themselves. It was assessed at 12 and then 24 weeks postpartum (Dennis, et al.,

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2009). It is shown to be effective, but was not chosen as the most effective intervention based on
lack of multiple studies that are high on the research hierarchy. Researchers suggest more studies
combining this intervention with other home-based interventions (Dennis & Dowswell, 2013).
Conclusion and Implications for Further Research
There are numerous studies on the treatment of postpartum depression but few on
prevention. Many prevention studies that I found are inconclusive, need additional research, or
are poor in quality. I selected CBT based off the success rate and strength of the supporting
evidence behind it, but this review needs more supporting research to increase the validity of its
claim that CBT is truly the most effective intervention for the prevention of PPD. Therefore, I
encourage more studies to be performed that focus on the prevention of PPD. I also believe more
studies that research the effectiveness of CBT alone versus CBT mixed with another promising
intervention could be useful in solidifying the validity of this approach. Lastly, my opinion is
that hormone therapy and peer-based phone support are the most promising alternative
treatments, and I would like to see more research done in both of these areas.
References
da Silva Magalhães, P. V., & Pinheiro, R. T. (2006). Pharmacological treatment of postpartum
depression. Acta Psychiatrica Scandinavica, 113(1), 75-76. doi:10.1111/j.1600-
0447.2005.00690.x
Dennis CL, Dowswell T. Psychosocial and psychological interventions for preventing
postpartum depression. Cochrane Database of Systematic Reviews 2013, Issue 2.
Art. No.: CD001134. DOI: 10.1002/14651858.CD001134.pub3.
Dennis, C., Hodnett, E., Kenton, L., Weston, J., Zupancic, J., Stewart, D. E., & Kiss, A. (2009).
Effect of peer support on prevention of postnatal depression among high risk

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women: Multisite randomised controlled trial. BMJ: British Medical Journal,
338(7689), 1-13.
Dennis CL, Ross LE, Herxheimer A. Oestrogens and progestins for preventing and treating
postpartum depression. Cochrane Database of Systematic Reviews 2008, Issue 4.
Art. No.: CD001690. DOI: 10.1002/14651858.CD001690.pub2.
Howard L, Hoffbrand SE, Henshaw C, Boath L, Bradley E. Antidepressant prevention of
postnatal depression. Cochrane Database of Systematic Reviews 2005, Issue 2.
Art. No.: CD004363. DOI: 10.1002/14651858.CD004363.pub2.
Johnson, G. (2011, July 6). Types of Postpartum Mood and Anxiety Disorders – Postpartum
Depression. Retrieved December 6, 2015, from
http://postpartumdepression.web.unc.edu/postpartum-depression/types-of-
postpartum-mood-and-anxiety-disorders/
Lefkovics, E., Baji, I. and Rigó, J. (2014), IMPACT OF MATERNAL DEPRESSION ON
PREGNANCIES AND ON EARLY ATTACHMENT. Infant Ment. Health J., 35:
354–365. doi: 10.1002/imhj.21450
Lewis, B. A., Gjerdingen, D. K., Avery, M. D., Sirard, J. R., Guo, H., Schuver, K., & Marcus, B.
H. (2014). A randomized trial examining a physical activity intervention for the
prevention of postpartum depression: The healthy mom trial. Mental Health And
Physical Activity, 7(1), 42-49. doi:10.1016/j.mhpa.2013.11.002
National Association of Cognitive-Behavioral Therapists (2014). What is Cognitive-Behavioral
Therapy? Retrieved December 6, 2015, from http://www.nacbt.org/whatiscbt.htm
Sockol, L. E. (2015). A systematic review of the efficacy of cognitive behavioral therapy for
treating and preventing perinatal depression. Journal Of Affective Disorders, 1777-

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21. doi:10.1016/j.jad.2015.01.052
Sockol, L. E., Epperson, C. N., & Barber, J. P. (2013). Preventing postpartum depression: A
meta-analytic review. Clinical Psychology Review, 33(8), 1205-1217.
doi:10.1016/j.cpr.2013.10.004