Comparisons of psychological and psychosocial treatments Cooper et al designed a large study to assess the effects of different psychological interventions on PPD. Other nonpharmacologic treatments for postpartum depression Many women suffering from PPD and their healthcare providers may seek alternatives or adjuncts to standard psychological or pharmacologic treatments because of their concern about the effects of pharmacological treatment on breastfeeding, access to care, issues of stigma in the treatment of mental illness, limited effectiveness, or personal beliefs.
Electroconvulsive therapy As with treatment-refractory major depression in the general population, electroconvulsive therapy ECT is an option for depressed postpartum women who do not respond to antidepressant medication or who have severe or psychotic symptoms. Bright light therapy While bright light therapy was initially introduced as a treatment for seasonal affective disorder, research has supported its effectiveness as a treatment for nonseasonal depression. Omega-3 fatty acids Omega-3 fatty acids have received specific attention in the treatment of perinatal depression, because of the known health benefits of these compounds for pregnant and postpartum women as well as some data showing positive effects on mood in the general population.
Acupuncture and massage Acupuncture is the ancient Chinese tradition of the inserting and manipulating needles into various points on the body to treat pathologic processes and relieve pain.
Exercise Several studies have investigated the role that exercise can play in alleviating postpartum depressive symptoms. Conclusion Postpartum depression is a major international public health problem that affects at least 1 in 8 mothers and their children in the year after childbirth worldwide.
Footnotes Disclosure The authors report no conflicts of interest in this work. Perspectives in Public Health. Depressive symptoms among pregnant women screened in obstetrics settings. The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in obstetrics. Barriers to service use for postpartum depression symptoms among low-income ethnic minority mothers in the United States. Rates and risk of postpartum depression: International Review of Psychiatry. Antenatal risk factors for postpartum depression: Antenatal risk factors for postnatal depression: Department of Reproductive Health and Research, World Health Organization Maternal mental health and child health and development in resource-constrained settings: Halbreich U, Karkun S.
Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. Journal of Affective Disorders. Gender, poverty, and postnatal depression: The impact of postpartum depression on mothering. J Obstetr Gynecol Neonat Nurs. The co-occurrence of smoking and a major depressive episode among mothers 15 months after delivery. The prevalence of postpartum depression among women with substance use, an abuse history, or chronic illness: Prevalence of suicidality during pregnancy and the postpartum. Arch Womens Ment Health. Fairbrother N, Woody SR. Thoughts of harming infants in depressed and non-depressed mothers.
Maternal infanticide associated with mental illness: The impact of postnatal depression and associated adversity on early mother infant interactions and later infant outcome. Maternal depression and parenting behavior: Postpartum depression effects on early interactions, parenting, and safety practices: Infant Behavior and Development. Externalizing and attentional behaviors in children of depressed mothers treated with a selective serotonin reuptake inhibitor antidepressant during pregnancy.
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Changes in antidepressant metabolism and dosing across pregnancy and early postpartum. Patient choice of treatment for postpartum depression: Treating depression during pregnancy and in the postpartum: Res Soc Work Pract. A controlled study of fluoxetine and cognitive-behavioural counseling in the treatment of postnatal depression. The use of paroxetine and cognitive-behavioral therapy in postpartum depression and anxiety: Pharmacologic treatment of postpartum women with new-onset major depressive disorder: Does maternal role functioning improve with antidepressant treatment in women with postpartum depression?
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Fluvoxamine for postpartum depression letter Am J Psychiatry. Bupropion SR for the treatment of postpartum depression: N Engl J Med. Prevention of postpartum depression: Prevention of recurrent postpartum depression: Accessed Aug 27, Blenning CE, Paladine H. An Approach to the postpartum office visit. Hanson LA, et al. Breast-feeding, a complex support system for the offspring. Jones G, et al. How many child deaths can we prevent this year? Evidence for the ten steps to successful breastfeeding. World Health Organization; The optimal duration of exclusive breastfeeding: The use of psychotropic medications during breast-feeding.
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Transdermal oestrogen for treatment of severe postnatal depression. Progesterone prophylaxis used successfully in postnatal depression. Gonadal steroids in the treatment of mood disorders. A double-blind randomized placebo controlled trial of postnatal norethisterone enanthate: Br J Obstet Gynaecol. Oestrogens and progestins for preventing and treating postpartum depression. Cochrane Database of Systematic Reviews.
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Comprehensive Guide to Interpersonal Psychotherapy. Interpersonal psychotherapy for postpartum depression: J Psychother Pract Res. Efficacy of interpersonal psychotherapy for postpartum depression. Psychotherapy for postpartum depression: Interpersonal psychotherapy adapted for the group setting in the treatment of postpartum depression. Group interpersonal psychotherapy for postnatal depression: A meta-analysis of the efficacy of cognitive therapy for depression. Journal of Consultation and Clinical Psychology.
What is cognitive behavioural therapy and does it work? This is in stark contrast with the raise in melatonin typically occurring about 2 h before habitual sleep time in healthy people, suggesting that this subset of participants had a major delay in evening melatonin release with a severe misalignment between melatonin rhythms and the sleep-wake cycle i.
After the intervention, melatonin did not reach the DLMO threshold within the 2 h following habitual sleep onset time in only 2 of these participants, suggesting that some degree of normalization in evening melatonin secretion took place during the intervention period for most participants. These changes in melatonin were accompanied by a mild phase advance in sleep onset time and a proportionate lengthening of total sleep duration.
This echoes previous findings suggesting that agomelatine improves sleep in people with depression 28 , 44 — The lack of significant changes in sleep efficiency during the intervention period could possibly be due to a ceiling effect. Despite the positive effects on sleep duration and on the alignment between endogenous melatonin rhythms and the sleep-wake cycle, the antidepressant effects of this multimodal intervention were significantly associated only with the phase advance in DLMO.
Thus, the physiological mechanisms of this intervention's mood enhancing effects in youths with depression may rely more heavily on the restoration of endogenous melatonin rhythms than on other sleep factors. We previously found high rates of misalignment between endogenous rhythms and the sleep-wake cycle in young people with depression, and this seemed to be mainly driven by a prominent phase delay in DLMO Consequently, for a large part of that population, adjusting the timing of melatonin release may be a critical factor for the restoration of biological rhythms and the alleviation of depressive symptoms.
From this perspective, agomelatine provided with psychoeducation and behavioral advice may trigger the correction of a measurable physiological abnormality known to affect a subgroup of people with depression. This type of treatment thus has the potential to be optimally targeted toward an identifiable subset of people with depression based on distinct pathophysiological profile. This study has several limitations. The sample size was small and some data was missing.
The lack of a placebo condition, and the multidimensional and adjunctive nature of the intervention preclude direct causal inference. Half of the participants were taking other psychotropic medications aside from agomelatine, but these medications were stable for at least 2 months prior to the adjunctive intervention start.
Therefore, it is unlikely that the continuous use of these other medications could solely explain all subsequent changes in depressive symptoms or possible indirect effects of depressive symptoms reduction on sleep or circadian rhythms during the adjunctive intervention. In addition, there was no significant difference in mood, sleep or circadian outcomes between participants who were taking other psychotropic medications as compared to those who were only taking agomelatine.
This strengthens the rationale for investigating chronotherapies as a primary treatment strategy in drug-free participants. Considering the possible synergistic effects of agomelatine on the melatonin and monoamine systems 47 , comparative trials with pure melatonin agonists and serotonin antagonists are required. Future comparative studies are also warranted to decipher the potential relative contributions of psychoeducational, behavioral and pharmacological components of multimodal chronobiotic interventions for depression. While this remains to be replicated in larger placebo-controlled double blind trials, this open-label study in young people with depression provides preliminary evidence suggesting that an adjunctive multimodal chronobiotic intervention combining a psychoeducation session about sleep and circadian rhythms with agomelatine intake in the evening could alleviate depressive symptoms, facilitate earlier secretion of higher levels of melatonin in the evening, and advance the timing of sleep onset time, while extending sleep duration.
In this small sample, the degree of phase advance in endogenous evening melatonin release was found to be a significant correlate of mood changes, suggesting that the antidepressant effects of the intervention may possibly be linked to the correction of a measurable physiological abnormality.
Overall, this strengthens the hypothesis that chronobiotic interventions may be especially effective to treat depression in people with circadian disruptions. If these findings are replicated, they could offer promising avenues for targeted treatment based on the prior identification of objective pathophysiological phenotypes.
Larger studies in more diverse samples are required to evaluate the relationship between initial circadian profile and the pattern of response to chronobiotic interventions. RR and DB developed the psychoeducational session. RR conducted the statistical analysis, and wrote the first draft of the manuscript.
All authors reviewed the final manuscript. This study was investigator-initiated, and Servier Australia Hawthorn, Victoria provided funding support for the study and supplied the medication. The supporters had no role in the design, analysis, interpretation, or publication of this study. The BMC operates an early-intervention youth services at Camperdown under contract to headspace. IH has previously led community-based and pharmaceutical industry-supported Wyeth, Eli Lily, Servier, Pfizer, AstraZeneca projects focused on the identification and better management of anxiety and depression.
The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The authors wish to thank the participants who took part to this study, as well as Mr.
The Supplementary Material for this article can be found online at: Agomelatine efficacy and acceptability revisited: Br J Psychiatry Aust NZ J Psychiatry Antidepressant efficacy of agomelatine: Agomelatine in the treatment of depressive disorders in clinical practice: Neuropsychiatr Dis Treat Pooled analysis of four non-interventional studies: Barbui C, Cipriani A. Agomelatine and the brave old world of narrative-based medicine. Evid Based Ment Health A benefit-risk assessment of agomelatine in the treatment of major depression. Agomelatine in the treatment of major depressive disorder: Efficacy of agomelatine in major depressive disorder: Complex interaction of the sleep-wake cycle and circadian phase modulates mood in healthy subjects.
Arch Gen Psychiatry PubMed Abstract Google Scholar. Mood change following an acute delay of sleep. Sleep and circadian rhythm disruption in psychiatric and neurodegenerative disease. Germain A, Kupfer DJ. Circadian rhythm disturbances in depression. How might circadian rhythms control mood? Biol Psychiatry Influence of sleep-wake and circadian rhythm disturbances in psychiatric disorders. Physiologic considerations underlying rhythmometry, with special reference to emotional illness.
Cycles Biologiques et Psychiatrie. Paris Georg; Masson Van den Hoofdakker RH. Chronobiological theories of non-seasonal affective disorders and their implications for treatment. J Biol Rhythms 9: Monteleone P, Maj M. The circadian basis of mood disorders: Circadian abnormalities, molecular clock genes and chronobiological treatments in depression. Chronotherapeutics in a psychiatric ward. Circadian misalignment in major depressive disorder.
Phase advance of the circadian sleep-wake cycle as an antidepressant. Bidirectional communication between sleep and circadian rhythms and its implications for depression: Manipulating the sleep-wake cycle and circadian rhythms to improve clinical management of major depression. Early evening melatonin and S advance circadian phase and nocturnal regulation of core body temperature.
The program makes use of common CBT principles and includes a Web-based discussion group. Also inspired by StudentBodies, Zabinski et al [ 45 ] developed a moderated synchronous group intervention for college-age women, called Chat Room. The main difference to StudentBodies is the integration of a synchronous communication chat room that enables participants to communicate more directly with each other. Stice et al [ 42 ] developed and evaluated the eBody Project, an Internet-based version of a CBT-based eating disorder prevention group-program.
The search yielded 3 prevention programs focused on the prevention of depression. Surviving and Thriving with Cancer [ 46 ] is an assisted Web-based education course aimed to foster positive health behaviors in cancer survivors. In addition to depression, intervention effects on health conditions as nutrition, exercise, and sleep were examined.
The intervention aims to prevent major depression episodes. It includes common CBT elements such as self-monitoring or relaxation techniques. Thompson et al [ 54 ] adapted a mindfulness-based prevention program UPLIFT for epilepsy patients with mild-to-moderate depressive symptoms [ 56 ]. The telephone- and Web-based intervention makes use of psychoeducative principles eg, knowledge about depression, importance of reinforcement and mindfulness-based tools eg, monitoring of thoughts.
The 6-week Web-based insomnia program SHUTi by Christensen et al [ 55 ] aims at the high co-occurrence of insomnia and depression. Overall, participants were recruited via the social network platform Facebook and randomized to either a CBT-based insomnia intervention or a control website HealthWatch. Two studies focused on combined anxiety and depression. A self-guided intervention promoting well-being in a general population was tested by Mitchell et al [ 50 ]. In 3 weekly sessions, users completed either an interactive program focusing on strengths intervention 1, based on positive psychology principles or problem-solving skills intervention 2.
Users received feedback and email reminders. MyCompass [ 53 ], a self-guided computer-delivered intervention, aims to foster self-management and self-monitoring skills in people with mild-to-moderate depression, anxiety, and stress symptoms. Content in the 12 modules was derived from CBT, interpersonal psychotherapy, problem-solving therapy, and positive psychology. Users are also provided with text messages or emails containing reminders and material on psychoeducation.
There were 2 studies that focused on post-traumatic stress. CBT techniques such as psychoeducation, stress management, and in vivo exposure are presented in the minute program alongside contact information for professional help and a Web forum for peer support. Cancer Coping Online, a self-guided Web-based CBT program for reducing distress in patients currently receiving cancer treatment, was evaluated by Beatty et al [ 47 ]. The 6-session program mainly focuses on coping strategies taught via text, audios, and worksheets.
Besides posttraumatic stress cancer-specific distress , levels of depression and anxiety general distress were evaluated. The search yielded 2 studies on GAD. MoodGYM [ 52 ] is a fully automated Internet-based program that teaches CBT skills eg, psychoeducation, relaxation, or mediation techniques to improve mental well-being in a general population. Besides well-being, depression and GAD data were gathered.
Because the mean depression score of the participants exceeded a clinical cutoff and thus did not fulfill inclusion criteria , only GAD data were included in this review. The intervention makes use of multiple CBT tools as psychoeducation, relaxation, or toolkits. Telephone reminders for participants without therapeutic purpose were included in one trial arm. Musiat et al [ 41 ] developed a transdiagnostic trait-focused program PLUS aiming to prevent common mental disorders. The CBT-based program focuses on the identification of strengths and the consolidation of coping strategies and includes computerized feedback.
Christensen et al [ 48 , 55 ] did not observe significant group differences in onset. Imamura et al [ 49 ] reported a significant onset difference for the month follow-up period 1. Calculations yielded an IRR of 0. Taylor et al [ 43 ] found an onset of 4. This yields an IRR of 0. In accordance to the Cochrane Handbook for Systematic Reviews [ 57 ], a correction of 0. The NNT was 9. Severity data were extracted for all included studies.
For the meta-analysis of depression interventions, we included studies with depression as a primary and secondary outcome. In cases of multiple active groups, only the main intervention sample was analyzed [ 48 , 50 ]. Results for short-, medium-, and long-term follow-up are presented in Figure 2 , Figure 3 , and Figure 4 , respectively.
In summary, pooled effect sizes, indicating a greater decrease in symptom severity for the intervention group, were small but significant.
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The effects of preventive interventions on symptom severity of depression at short-term FU—comparison experimental versus control group. The effects of preventive interventions on symptom severity of depression at medium-term FU—comparison experimental versus control group. The effects of preventive interventions on symptom severity of depression at long-term FU—comparison experimental versus control group. According to Higgins et al [ 58 ], overall level of heterogeneity was moderate to high.
Sixty-two records were selected as likely being relevant. Most of those were planned studies on symptom severity as a secondary outcome and with different study purposes. Eleven records aimed to assess severity data and had an explicit preventive goal. Targeted conditions were mostly mood and anxiety disorders. Seven studies planned to use clinical interviews for diagnostics or to explicitly gather incidence data. Three studies of those studies were already published, one of them is included in this review [ 49 ] and 2 were excluded because of high symptom severity or diagnosis inclusion criteria 2 at baseline [ 59 , 60 ].
Another planned study on depression had been withdrawn before enrolment because of missing funding ClinicalTrials. Of the remaining 3 records, one study is planned on the prevention of psychosis for people with psychotic like experiences Australian New Zealand Clinical Trials Registry, registration no. Our own research group also conducts a clinical trial on the prevention of depression in the risk-group of back pain patients with subthreshold depressive symptoms, which is registered at the German Clinical Trials Register registration no.
Inspection study protocols emerging from the data base search yielded ongoing trials for the prevention of depression [ 61 - 64 ] and PTBS [ 65 ]. This review and meta-analysis systematically summarizes previous research on Internet-based interventions for the prevention of mental disorders. It therefore exceeds the informative value of existing reviews eg, [ 23 , 67 ] in terms of the range of included disorders and gives an extensive overview of the actual state of research.
Seventeen RCTs were included in this review and described in detail. Results are in line with previous meta-analyses, showing that indicated and selective prevention is more common than universal prevention [ 13 ] and that CBT is a frequently sometimes even exclusively used Internet-based intervention type eg, [ 24 , 66 ]. Quality assessment suggests that 5 included studies have a high risk of bias. Some biases are inevitable eg, blinding not possible for psychological interventions.
Others, such as biases due to inappropriate randomization, can and should be avoided. Of note, 3 studies were classified as having high risk of bias solely due to a serious flaw. Reasons for study classification as having a serious flaw included baseline differences between intervention and control groups [ 43 , 53 ], very low compliance with the intervention [ 50 , 53 ], and a very high dropout rate [ 50 ]. Concerning study dropout, the Cochrane guideline [ 36 ] provides a rather conservative appraisal when applied to IMIs [ 67 ]. When evaluating treatment dropout, a more differentiated perspective can be beneficial.
In a recent meta-analysis, van Ballegooijen et al found that IMIs regularly have lower completer rates of total interventions when compared with face-to-face treatments Above that, participants do not necessarily have to complete all sessions to benefit from IMIs.
They may stop the treatment because they already obtained benefit, and therefore, these cases would represent a success, rather than a treatment dropout [ 69 , 70 ]. Three of 5 studies reporting incidence data provided evidence for a preventive effect of the investigated interventions [ 43 , 49 , 54 ]. One study failed to report the results of a diagnostic interview, which would have allowed calculating incidence rates [ 39 ]. The remaining studies by Christensen et al [ 48 , 55 ] did not find effects on reduction of new cases.
However, secondary outcome measures of anxiety and depression symptoms showed positive effects. The included incidence studies differed in the length of follow up-periods. Thompson et al [ 54 ] only had a pre-post comparison. For the remaining studies, incidence reduction could be observed over a month follow-up period [ 43 , 49 ], suggesting that preventive interventions have the potential for incidence reduction in the long term.
Nevertheless, severity data show positive effects of interventions in 11 of 17 studies with small-to-medium effect sizes. The best evidence was found for ED and depression. Our meta-analysis on IMIs for depression showed an overall small but significant reduction in symptom severity. As mentioned before, this demonstrates an effect of IMIs on the treatment of subclinical depression; a subsequent reduction of incidence can only be assumed, as most included studies did not report incidence data.
Because of moderate to high levels of heterogeneity, the actual effect size values should be interpreted with caution. Nevertheless, heterogeneity results from estimates showing the same direction of effect favoring interventions over control groups. In summary, evidence was found for effectiveness of interventions for EDs, depression, and anxiety. Internet-based interventions can be considered effective in reduction of subthreshold symptomatology and may also be suitable for preventing the onset of mental disorders over the long term.
Depression and anxiety are of particular clinical relevance against the background of prevalence rates: Although many IMIs include modules on sleep or relaxation eg, [ 47 , 50 ] , Christensen et al  reported the first prevention RCT explicitly targeting insomnia resulting in a reduction in depressive symptomatology. A number of potential limitations and challenges regarding this study should be acknowledged.
As usual for reviews and meta-analyses, publication bias [ 71 ] must be assumed. This review included several studies reporting not expected or nonsignificant results; nevertheless, publication bias cannot be precluded. Furthermore, the search might have been confounded by language bias because only English and German papers were included.
Treatment of postpartum depression: clinical, psychological and pharmacological options
Fortunately, in contrast to publication bias, this only minimally impacts conclusions [ 72 ]. Another limitation concerns the inclusion of studies that reported mean scores only and did not clearly state that participants did not exceed clinical cutoffs at baseline second exclusion criterion. This became evident after contacting authors to obtain raw data and subsequently computing incidence and onset rates if they had not already been reported. Four of those studies [ 73 - 76 ] had to be excluded because inspection of the raw data revealed that a considerable number of participants exceeded clinical cutoffs at baseline, even though the other eligibility criteria had been fulfilled.
Unfortunately, only a few authors responded to our requests for additional information. Thus, it cannot be ruled out that this might also be the case for some included studies, that is, those which reported mean scores and did not provide raw data. One major challenge of this broad review was the handling of variability between studies. Although heterogeneity was expected, and even welcomed to map out the broad scope of existing e-mental health prevention interventions, it must be taken into account when interpreting the findings. There are several sources of heterogeneity.
First, this review was not restricted to one mental disorder but included a number of clinical conditions. Second, methods to determine the clinical status of participants, such as structured clinical interviews or self-report questionnaires, differed between studies. Third, intervention contents were different. As mentioned previously, most interventions were based on CBT, but other intervention types were included as well. Fourth, study design caused heterogeneity, due to different types of control groups, varying follow-up assessment periods and different sample sizes.
For the meta-analysis, pooled effect sizes were calculated for depression and grouped into 3 follow-up periods. Nevertheless, different sample sizes can lead to overweighting of the larger size studies. To gain insight into requirements for future research, limitations of the presented studies should be considered. First, the 5 included incidence studies were planned with preventive goals and used standardized clinical interviews for valid diagnosis. The remaining studies were often planned for other purposes eg, improving well-being , and mental disorder symptoms were gathered by means of self-report questionnaires.
Therefore, additional incidence studies using valid diagnostic instruments are needed, especially in light of the ICTRP search results, which revealed that very few incidence studies are planned in the near future.
Second, the evidence base is limited to a handful of disorder groups specifically EDs, depression and anxiety. Research could expand to the missing subfields, for which Internet-based prevention could be applicable. It is noteworthy that one ongoing trial targets prevention of psychosis [ 77 ]. Third, this is the first exhaustive review on Internet-based prevention for mental disorders in adults. One could expand the scope to additional domains and populations, for instance to relapse prevention in mentally ill persons.
As there are already several studies on this topic eg, [ 78 , 79 ] , a systematic review would be beneficial to provide an overview of the current state of research. Another potential field of study could be Internet-based prevention of mental disorders in children and adolescents. There is already one review on this topic [ 66 ], which is limited to depression and anxiety, but could be expanded to include other mental disorders.
Fourth, most Internet-based interventions included in this review had no additional human support component ie, unguided.
Although this results in a reduction of initial costs, it is also accompanied by a reduction of effectiveness [ 80 ]. To date, there is no study investigating whether or not this reduced effectiveness translates into an increase in costs over the long term, due to for example increased health care utilization or work incapacity days. Internet-based interventions can be effective in the primary prevention of mental disorders. The body of research is still limited to a few mental disorders EDs, depression, anxiety disorders. Therefore, further high-quality studies are required, using standardized clinical interviews and gathering incidence data in long-term follow-ups.
Because of the advantages of Internet-based interventions such as cost-effectiveness, availability, and flexibility [ 16 , 17 ], this can be a fruitful area for research. Content could be adapted for use with other disorders and populations. Furthermore, interventions that have been found to be effective in preventing certain mental disorders can and should be implemented into practice. Health care costs and personal, social, and financial burdens of the affected and society can consequently be reduced.
The authors would like to thank Yannik Terhorst for proofreading of the manuscript and Mary Wyman for language editing. Effectiveness of a guided web-based intervention for depression in back pain rehabilitation aftercare, grant number: The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
LS and LR had major contributions to data extraction and analysis. All authors had major contributions to the write-up and editing of the manuscript and read and approved the final manuscript. National Center for Biotechnology Information , U. Published online Aug