Universal prevention of depression in women postnatally: cluster randomized trial evidence in primary care.
BACKGROUND
To test whether receiving care from a health visitor (HV) trained in identification and psychological intervention methods prevents depression 6-18 months postnatally in women who are not depressed 6 weeks postnatally.


METHODS
The study was a prospective cluster trial, randomized by GP practice, with follow-up for 18 months in 101 primary care teams in the Trent area of England. The participants were women scoring <12 on the postal Edinburgh Postnatal Depression Scale (EPDS) at 6 weeks postnatally (1474 intervention and 767 control women). Intervention HVs (n=89, 63 clusters) were trained in identifying depressive symptoms using the EPDS and face-to-face clinical assessment and in providing psychologically orientated sessions based on cognitive behavioral or person-centered principles. The control group comprised HVs (n=49, 37 clusters) providing care as usual (CAU). The primary outcome measure was the proportion of women scoring ≥ 12 on the EPDS at 6 months postnatally. Secondary outcomes were mean EPDS score, Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) score, State-Trait Anxiety Inventory (STAI), 12-item Short Form Health Survey (SF-12) and Parenting Stress Index Short Form (PSI-SF) scores at 6, 12 and 18 months.


RESULTS
After adjusting for individual-level covariates, living alone, previous postnatal depression (PND), the presence of one or more adverse life events and the 6-week EPDS score, the odds ratio (OR) for EPDS ≥ 12 at 6 months was 0.71 [95% confidence interval (CI) 0.53-0.97, p=0.031] for the intervention group (IG) women compared with the control (CAU) group women. Two subgroups were formed by baseline severity: a 'subthreshold' subgroup with a 6-week EPDS score of 6-11 (n=999) and a 'lowest severity' subgroup with a 6-week EPDS score of 0-5 (n=1242). There was no difference in psychological effectiveness by subgroup (interaction term: z=-0.28, p=0.782).


CONCLUSIONS
This study provides new evidence of a universal, enduring preventive effect for depression in women who screen negative for depression postnatally.
Brugha
T S
TS
Clinical Division of Psychiatry, Department of Health Sciences, University of Leicester, Leicester, UK. tsb@leicester.ac.uk
Morrell
C J
CJ
Slade
P
P
Walters
S J
SJ
D000328:Adult; D016000:Cluster Analysis; D015928:Cognitive Behavioral Therapy; D003152:Community Health Nursing; D019052:Depression, Postpartum / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology* / Q000628:therapy; D004739:England; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008016:Life Change Events; D011320:Primary Health Care; D011795:Surveys and Questionnaires