As many as one in seven women experience depression during pregnancy or in the year after giving birth. Now, for the first time, a national panel of health experts says there is a way to prevent it.
Some kinds of counseling can keep some women from developing debilitating symptoms that can harm not only them but their babies, the panel reported on Tuesday. Its report amounted to a public call for health providers to seek out women with certain risk factors and guide them to counseling programs. The recommendation, by the United States Preventive Services Task Force, means that insurers will be required to cover those services — with no co-payments — under the Affordable Care Act.
“We really need to find these women before they get depressed,” said Karina Davidson, a task force member and senior vice president for research for Northwell Health.
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Perinatal depression, as it is called, is estimated to affect between 180,000 and 800,000 American mothers each year and up to 13 percent of women worldwide. The condition increases a woman’s risk of becoming suicidal or harming her infant, the panel reported. It also increases the likelihood that babies will be born premature or have low birth weight, and can impair a mother’s ability to bond with or care for her child. The panel reported that children of mothers who had perinatal depression have more behavior problems, cognitive difficulties and mental illness.
The panel emphasized that perinatal depression is shouldn’t be confused with “baby blues” — the tears, irritability, fatigue, and anxiety that many women experience after delivery but which evaporates within 10 days.
The panel evaluated research on numerous possible prevention methods, including physical activity, education, infant sleep advice, yoga, expressive writing, omega-3 fatty acids and antidepressants. Several showed some promise, including physical activity and programs in Britain and the Netherlands involving home visits by midwives or other providers. But only counseling demonstrated enough scientific evidence of benefit.
Beth Sanfratel of Birmingham, Ala., said she wished she had been in a counseling program when pregnant with Mac, left, the second of three sons. “I was having trouble getting up and in general just being really bummed out,” she said.CreditWes Frazer for The New York Times
Women receiving one of two forms of counseling were 39 percent less likely than those who didn’t to develop perinatal depression. One approach involved cognitive behavioral therapy, helping women navigate their feelings and expectations to create healthy, supportive environments for their children. The other involved interpersonal therapy, including coping skills and role-playing exercises to help manage stress and relationship conflicts.
“This recommendation is really important,” said Jennifer Felder, an assistant professor of psychiatry at University of California, San Francisco, who was not on the panel. “This focuses on identifying women who are at risk for depression and proactively preventing its onset, using concrete guidelines.”
The panel recommended counseling for women with one or more of a broad range of risk factors, including a personal or family history of depression; recent stresses like divorce or economic strain; traumatic experiences like domestic violence; or depressive symptoms that don’t constitute a full-blown diagnosis. Others include being a single mother, a teenager, low-income, lacking a high school diploma, or having an unplanned or unwanted pregnancy, panel members said.
It highlighted two specific programs, which were similarly successful, Dr. Davidson said. They counsel first-time mothers and those who already have children. They are available in Spanish and focus on low-income women, about 30 percent of whom develop perinatal depression, experts say.
One program, “Mothers and Babies,” includes cognitive behavioral therapy in eight to 17 group sessions, often delivered in clinics or community health centers, primarily during pregnancy with at least two sessions postpartum.
“It’s really meant to break down this idea that talking about your thoughts and behaviors is scary,” said Darius Tandon, an associate professor at Northwestern University’s Feinberg School of Medicine and principal investigator of several “Mothers and Babies” studies.
So far, health and human service agencies in over 175 counties in 21 states have been trained to implement the program. It is also being evaluated in Florida and the Midwest to see if it works when administered one-on-one by home visiting caseworkers instead of groups run by psychologists or social workers, Dr. Tandon said.
The other program, “Reach Out, Stay Strong, Essentials for New Moms” or ROSE, typically delivered in four sessions during pregnancy and one postpartum, can be administered in groups or one-on-one by nurses, midwives or anyone trained to follow the manual, said Jennifer Johnson, a professor of public health at Michigan State University.
So far, women in Rhode Island, Mississippi and Japan have participated, said ROSE’s creator, Caron Zlotnick, a professor of psychiatry and human behavior at Brown University. She and Dr. Johnson are testing its expansion to 90 clinics throughout the country.
Karla Manica, 30, a single mother of four in Detroit, participated in “Mothers and Babies” when pregnant with her youngest, who is now 1. She said she experienced abuse as a child and in relationships, attempted suicide by drinking cleaner, lived in homeless shelters after being laid off from her job as a dementia caregiver, and has had bipolar depression.
“It was good to come to the table and share,” Ms. Manica said. The counselor texted uplifting messages between sessions, and “homework assignments” to engage in stress-relieving activities were useful. When Ms. Manica learned her baby’s father had another girlfriend, she said, the group “gave me hope.”
After her daughter Kathryn was born, “I was well,” Ms. Manica said. “If I hadn’t got with the Mothers and Babies, would I have been prepared, would I have gotten the confidence I have now? No.”
Experts and leaders of the programs, whose curriculums and counselor training are free, said financial and other obstacles exist.
“Cost is definitely still an issue,” said Dr. Tandon. He said one prenatal session costs clinics delivering the counseling $40 to $50 to provide mothers’ transportation and child care, and Medicaid doesn’t have a reimbursement code for preventive counseling, so clinics often absorb the cost of staff time to provide it.
Access to counseling also can be difficult. “Especially when you’re pregnant and you have competing demands on your time and energy, or if you have a little one at home,” said Dr. Felder, who wrote an editorial about the recommendation. Offering it online or through apps may help.
Even in some cases in which it doesn’t prevent depression, counseling may be beneficial, said Dr. Melissa Simon, a task force member and vice chairwoman of research at Northwestern’s Feinberg School of Medicine’s obstetrics and gynecology department. “It provides the pregnant person with education and coping strategies,” she said, and can encourage those who develop depression to seek treatment faster.
Captoria Porter, 28, of Bolingbrook, Ill., who has seven children, ages 2 months to 11, experienced no depression during or after her first five pregnancies. But during her sixth, life became more tumultuous, with marital problems and the need to move in with her sister because the housing project where she was living was closing.
After the birth of Myla, now 1, “I think I had symptoms of depression,” said Ms. Porter, who has worked as a telemarketer selling sanitizer dispensers. “I was really sad.”
Fortunately, the pre-birth “Mothers and Babies” sessions helped her recognize signs like “you don’t want to brush your hair or you don’t want to be bothered with the baby,” she said. “I would find myself feeling that way.”
Ms. Porter met twice with a community center counselor, but realized the program had already taught her the practices he recommended: “Reaching out to family and friends. Learning that I can’t control everything. Eating when the baby eats, sleeping when the baby sleeps, laying the kids down for a nap and calling it ‘me time.’”
That warded off full-blown depression. “I caught it early,” she said.
The panel encouraged more research on all prevention approaches. In reviewing 50 studies of various methods, it found negative effects only in the two small studies with antidepressants. One study reported instances of dizziness and drowsiness among women who took Zoloft. The other reported that more women taking Pamelor experienced constipation.
“Some people have asked, ‘Why aren’t you just recommending antidepressants?’” Dr. Davidson said. “Of course, antidepressants were developed and studied for someone who has depression. We need to consider possible benefits and possible harms to parent and fetus when someone is not depressed and you’re giving them a drug to treat depression on the off-chance it prevents depression.”
Beth Sanfratel, 43, a preschool teacher in Birmingham, Ala., said she wished she’d had a counseling program when pregnant with the second of three sons, Mac, now 10.
“I don’t even think postpartum depression was mentioned,” she said. Several months after Mac was born, Ms. Sanfratel, usually upbeat and social, said she began having crying spells. “I was having trouble getting up and in general just being really bummed out.”
Ultimately, Ms. Sanfratel, a former social worker, recognized she needed help and took antidepressants for about a year, resuming them shortly before her third son, Beau, was born in 2011.
“Getting moms figuring out what’s going on ahead of the actual delivery, it’s a great, great thing,” she said.
