A systematic review of 44 randomized controlled trials (n = 5,926) evaluated the effectiveness of cognitive behavioral therapy, interpersonal therapy, behavioral activation, and nondirective counseling for perinatal depression. Both cognitive behavioral therapy and interpersonal therapy probably reduce depressive symptoms compared with usual care, while behavioral activation may also offer benefit. Evidence for nondirective counseling remains unclear.
CBT Shows Moderate Effectiveness
Across 25 cognitive behavioral therapy (CBT) trials (n = 2,962), participants reported moderate reductions in depressive symptoms compared with those receiving usual care, equivalent to approximately 1.7 points on the Edinburgh Postnatal Depression Scale (EPDS). Recovery from depressive symptoms occurred more frequently among those treated with CBT. The strength of evidence (SoE) was moderate for symptom reduction and low for recovery. CBT probably also reduces anxiety symptoms (moderate SoE).
IPT Demonstrates Similar Benefits
Across nine interpersonal therapy (IPT) trials (n = 1,003), patients showed similar reductions in depressive symptoms (≈ 1.7 EPDS points) and higher recovery rates than those receiving usual care (moderate SoE for symptom reduction, low SoE for recovery). However, results showed substantial statistical heterogeneity (I² ≈ 81%), and in several studies, the comparator was enhanced usual care, which may have narrowed between-group differences. IPT showed no clear difference for anxiety outcomes (low SoE).
Behavioral Activation May Be Effective
Three behavioral activation (BA) studies (n = 508) demonstrated reductions in depressive symptoms equivalent to about 1.5 EPDS points compared with usual care, though the strength of evidence was low due to the limited number of studies.
Nondirective Counseling May Offer No Difference
Nondirective counseling may have no difference versus usual care (low SoE). Direct comparisons between CBT and counseling showed no clear difference in depressive symptom outcomes.
Consistency Across Settings and Delivery
Subgroup analyses found no meaningful variation in effect by perinatal timing (pregnancy vs postpartum), therapy delivery method (individual, group, online), interventionist background (therapist, nurse, peer), or treatment setting—indicating that therapy benefits are generally consistent across formats and populations.
Clinical Significance Unclear
Effect sizes were converted to approximate EPDS point differences. A clinically meaningful EPDS threshold has not been established; thus, the observed reductions of ~1.7–2.6 points are considered small and may not constitute a clinically meaningful difference at the individual level.
Study Limitations
Most trials had a moderate risk of bias, primarily because blinding of participants and assessors was not feasible. Additionally, nearly all studies were conducted in high-income countries with predominantly White, educated participants, limiting generalizability to low-resource or underrepresented populations.
Clinical Implications
These findings update and refine the context of the 2019 U.S. Preventive Services Task Force (USPSTF) statement recommending nondirective counseling, CBT, or IPT for perinatal depression. The current review suggests that CBT and IPT have probable effectiveness (moderate SoE), while nondirective counseling shows no clear benefit over usual care.
The review was funded by the Agency for Healthcare Research and Quality (AHRQ) to inform upcoming clinical practice guidelines from the American College of Obstetricians and Gynecologists (ACOG).
Source: Annals of Internal Medicine
