The efficacy of cognitive behavioral therapy for the treatment of antenatal depression: A systematic review

Highlights

• CBT has been shown to be effective at reducing the severity of depression symptoms in pregnancy.

• There is no specific diagnostic tool for measuring the severity of depression for pregnant women.

• The variety of tools used mean a meta-analysis to quantify the effectiveness of CBT is not feasible.

Abstract

Background

Antenatal depression affects 7–20% of pregnant women globally yet less than a fifth of such women receive adequate treatment. Cognitive behavioral therapy (CBT) is known to be effective in the treatment of depression. However, the research is more limited with regard to the antenatal period suggesting a need for clearer evidence within this field.

Objective

To determine if CBT is effective in the treatment of antenatal depression.

Methods

Medline, Embase, PsychINFO, CINAHL and CENTRAL were searched for studies that quantified the effectiveness of CBT in women with a confirmed diagnosis of antenatal depression. Randomised controlled trials that measured the effectiveness of CBT delivered during the antenatal period, compared to another intervention or usual care, measured using a validated depression score pre and post intervention were included.

Results

Five RCTs were eligible for inclusion, all of which found a significant decrease in depression scores following CBT interventions, greater than that observed in control groups. Improvements in depressive scores were maintained long-term for participants who received CBT. Participant satisfaction with the interventions received was high.

Limitations

Studies included displayed major performance biases, and language bias is present due to exclusion of an Iranian paper.

Conclusion

CBT, tailored to pregnant women, is effective in the treatment of antenatal depression, with little difference in efficacy between CBT sub-types. Further large-scale RCTs are needed to confirm these hypotheses and determine the most cost-effective way of delivering CBT to pregnant women. There is also need for a specific, validated tool for assessing antenatal depression.

Introduction

Antenatal depression, defined as depression during pregnancy up to the point of birth, affects between 7 and 20% of mothers-to-be globally (Leigh and Milgrom, 2008) with the prevalence found to be highest in developing countries (Castro E Couto et al., 2016). Moreover, less than a fifth of women suffering from this condition actually receive adequate treatment (Byatt et al., 2016). Vesga-López et al. (2008) found pregnancy per se was not associated with increased risk of depression. The symptoms of depression are, however, often overlooked during pregnancy and instead considered to be normal somatic experiences, so the true prevalence of this condition may have been underestimated (Wichman and Stern, 2015). The rates of antenatal depression are comparable with those of postnatal depression, yet the latter condition is far more heavily researched. This is likely due to previous theories of pregnancy protecting women against depression, which have since been disproven (Waters et al., 2014).

With regard to the cause of antenatal depression, multiple psychosocial risk factors have been identified. These include: low socioeconomic status and educational attainment, low self-esteem, lack of social support, major life events such as miscarriage, history of abuse and depression and being of a young age at the time of first pregnancy (Leigh and Milgrom, 2008). The signs and symptoms of depression include feelings of sadness, worthless, hopelessness, irritability and fatigue, along with loss of interest in activities previously enjoyed and alterations to sleep and eating patterns. Symptoms specific to depression during the antenatal period are negative thoughts concerning motherhood and the baby. Women may also portray self-harm behavior and suicidal ideation (Haring et al., 2011).

If left untreated, antenatal depression can be hugely detrimental to both mother and foetus. On top of being a debilitating condition for women during pregnancy, antenatal depression has extensive negative impacts after birth, with mothers who suffered from depression during pregnancy at higher risk of developing postnatal depression (Pampaka et al., 2019). Breastfeeding duration is also impacted upon, with early breastfeeding cessation observed in these women (Figueiredo et al., 2014).

Antenatal depression is associated with a vast range of adverse outcomes for offspring, from infancy into adolescence (Entringer et al., 2015; Gentile, 2017). Infants born to mothers with depression during the third trimester are at increased risk of low birth weight and growth retardation at 1 year of age (Rahman et al., 2007; Grote et al., 2010). At 18 months, reduced cognitive development has been observed in these infants too (Koutra et al., 2013). Prenatal exposure to maternal stress is associated with an increased risk of psychiatric disorders throughout life (Entringer et al., 2015; Van den Bergh et al., 2017). The literature also suggests that antenatal depression is a predictor of antisocial and violent behaviour in adolescence (Hay et al., 2010; Gentile, 2017). With so much evidence detailing the negative consequences of antenatal depression, an effective treatment strategy is of paramount importance.

Cognitive behavioral therapy (CBT) is known to be in the effective treatment of depression (Ramanuj, Ferenchick and Pincus, 2019). It is a form of talking therapy focussed on how a patient's thoughts and attitudes affect their behaviour. It is based on the principle that maladaptive cognitions contribute to emotional distress and negative behaviours and identifying and challenging these can lead to change (Hofmann et al., 2012; Coffey et al., 2015). CBT interventions take a wide variety of forms; they may be one-on-one, group sessions, internet-based, or focussed on mindfulness to name a few (NICE, 2009).

Given the unique nature of pregnancy compared to any other period of life the requirements for depression treatment may be different for pregnant women. NICE recommends treatment with a high-intensity psychological intervention, such as CBT, or prescription of antidepressant medication (NICE, 2018). However, these recommendations are based on limited antenatal research with evidence often of low quality (Hofmann et al., 2012). Furthermore, many women are reluctant to use antidepressants during pregnancy due to beliefs that they pose high risk to the foetus (Petersen et al., 2015), even in spite of research to the contrary (Prady et al., 2018). As such, the need for firm evidence regarding the efficacy of CBT for treatment of antenatal depression is of crucial importance.

Previous reviews have evaluated interventions for the prevention and treatment of perinatal depression and suggest that CBT may play an important role. However, these discuss additional interventions, rather than CBT alone, and may not be limited to the antenatal period. The studies included in these reviews are often of poor quality too, as they do not solely evaluate randomised controlled trials, calling into question the amount of weight that can be placed on this evidence (Dennis, Ross and Grigoriadis, 2007; Sockol, Epperson and Barber, 2011; Chowdhary et al., 2014; Sockol, 2015; van Ravesteyn et al., 2017). Given the wide range of subtypes of CBT treatment available, a clearer understanding surrounding the most efficacious forms would also be beneficial. Thus, this systematic review will be addressing a lack of clarity within the current literature regarding the role that CBT may play in the treatment of antenatal depression, which may inform future research and have implications for public health.