Around 20% of women during the perinatal period experience peripartum depression (PPD). PPD has been found to have significant impacts on the mental health of mothers, babies and parent-child relationships and is suggested to bring about a lifetime cost of £75,000 per woman diagnosed (Bauer et al., 2016).
Despite its impacts on mothers and babies, the existing (limited) clinical guidelines on PPD have significant inconsistencies. There is also a lack of recommendations on prevention and psychological interventions (see this blog for systematic reviews on psychological interventions during the perinatal period).
On the other hand, in terms of implementation of guidelines, a systematic review has shown that despite guideline recommendations, routine screening and referrals of PPD are not implemented in most healthcare services (Yang et al., 2024).
Sandra et al. (2025) reviewed the existing evidence for PPD and developed new clinical guidelines on prevention, screening and treatment of PPD.
Current guidelines for peripartum depression are inconsistent and not routinely implemented. These new guidelines aim to overcome these issues.
Methods
A Guideline Development Group (GDG) was formed to review the existing evidence and develop the guidelines based on the World Health Organization (WHO) manual for developing guidelines for clinical practice. The group included 14 specialists in the perinatal mental health field across multiple disciplines (psychiatry, psychology, etc.) from 12 countries as well as a patient representative association.
The GDG first conducted a literature review regarding the prevention, screening and treatment of PPD. Ten questions on population, outcomes, comparison and outcomes (PICO) were developed to guide the literature review process and 6 search strategies were used to address the questions. In terms of evidence review, (1) when an updated umbrella review was available with one of the members of the GDG as one of the authors, the umbrella review was analysed. (2) A new search was conducted when the umbrella review was outdated or not available. Systematic reviews and meta-analyses conducted in English from 2010 to 2023 were included in the literature review and a quality assessment was conducted using the AMSTAR 2 tool (Shea et al., 2017).
The quality of evidence was assessed by the GRADE system (GRADE working group, 2013). The members of GDG responsible for each PICO question presented the analysed evidence and their recommendations to the GDG. The decision on inclusion of the recommendation was then made based on the consensus of the GDG. The recommendation development was guided by the AGREE II instrument (Brouwers et al., 2010) and the strength of each recommendation was reported as strong, weak or no recommendations.
Results
145 systematic reviews were included in the development of the guidelines. The results of evidence and recommendations were as follows:
Prevention of Peripartum Depression
- There was insufficient evidence to support the use of antidepressants or dietary supplements to prevent PPD
- Evidence suggested that both women with known risks and those with no known risks would benefit from receiving psychological and psychosocial interventions such as CBT, interpersonal therapy, postpartum professional home-based visits, midwifery-redesigned postnatal care and postpartum lay-based telephone support
- Women during the perinatal period could benefit from physical activities such as stretching, pilates, aerobics and at least 90 minutes of physical activity per week
Screening for Peripartum Depression
- Screening has the potential to reduce depressive symptoms, with the combination of interventions such as treatment protocols, care management, availability of personnel trained on screening and providing PPD treatment.
- Indirect evidence suggested that screenings can identify women who need further assessment and treatments. Also, high patient satisfaction towards screening programmes were reported and screenings were found to be cost-effective by 2 studies.
- Despite this, there was limited evidence on the effectiveness of screening in detecting the presence of risk factors for vulnerability to depression. Further research on cost-effectiveness, feasibility and efficacy of high-risk assessment is needed.
- No recommendations on timing and screening tools could be made due to heterogeneity regarding instruments used and screening timing in the literature.
- It is recommended that PPD screenings should only be offered when systems are in place to ensure women with positive results are properly diagnosed and received timely referral to receive treatments by adequately trained professionals.
Treatment of Peripartum Depression
- Psychological interventions, particularly CBT are recommended to treat PPD. The evidence of effectiveness of third-wave techniques and interpersonal therapy is weak.
- In terms of pharmacological interventions, individual risk-benefit ratio (previous history, severity of symptoms, patient preference, and availability of alternative treatments) should be carefully assessed for the prescription of antidepressants. There is no evidence that one specific type of antidepressant is more effective in treating PPD.
- There is limited evidence on antidepressant medication on PPD due to ethical concerns of conducting trials. However, there is strong evidence of untreated depression having adverse effects on exposed children.
- Discontinuation of antidepressant treatment is not recommended for women with a history of severe and recurrent PPD due to risk of relapse. However, monotherapy and lowest effective dose should be used to reduce negative impacts of medication.
- Note: If you are interested in finding out more about the safety of antidepressants and other mental health medications during pregnancy, please read Flo Martin’s blog from 2024.
- In terms of non-invasive brain stimulation:
- Repetitive transcranial magnetic stimulation is recommended based on its effectiveness for depression and safety among the general population despite the limited evidence on its effectiveness. It can be an alternative treatment for perinatal women with mild to moderate depressive symptoms according to their clinical conditions, values and preferences.
- Electroconvulsive therapy (ECT) is strongly recommended in the case of life-threatening, therapy-resistant severe PPD. During pregnancy, ECT should be held in hospital setting by experienced healthcare team including obstetricians and warrant strict supervision. Existing evidence on ECT is of low quality. Recommendations are made based on clinical experience of experts in GDG where risks are considered as outweighing benefits in life threatening situation.
- No recommendations can be made on bright light therapy due to low quality and lack of evidence.
- In terms of complementary and alternative treatments:
- Fatty acids can potentially reduce mild to moderate depressive symptoms and with trivial adverse effects. However, the quality of evidence is low to moderate.
- There was evidence that physical exercise, including yoga, as well as massage may improve depressive symptoms during pregnancy, however there was limited evidence of the efficacy of these treatments in the postpartum period.
- The literature did not support any recommendations on peer support, acupuncture, Chinese herbs or music therapy.
Evidence suggests that psychological intervention like CBT is effective in preventing and treating peripartum depression and screening programmes can detect and reduce PPD symptoms.
Conclusion
The authors developed clinical guidelines for peripartum depression including 44 recommendations for prevention, screening and treatment of PPD after conducting an extensive review of existing evidence. The authors recommended the guidelines be adopted on a national level among European countries to improve the mental health care that women and babies receive.
The authors developed 44 recommendations focusing on prevention, screening and treatment of peripartum depression.
Strength and limitations
The study involved an extensive literature review across broad areas of prevention, screening and treatment. Particularly, it reviewed areas that are not covered sufficiently in current guidelines, for instance the effectiveness of screening to identify risks of developing PPD. These recommendations can lead to more comprehensive perinatal mental health care especially around prevention of PPD.
The study also clearly reported the methodology of the literature review with the quality of evidence assessed by the tool (Shea et al., 2017) and (GRADE working group, 2013) and guideline development following the golden standard of the checklist (Brouwers et al., 2010). Also, the guideline development group had a diverse representation from both professionals (experts across disciplines from 12 countries) and patients.
However, as a widespread issue in research, the author acknowledged that the studies included were mainly English studies from high-income countries which impacts the cultural representativeness of the recommendations and its application to healthcare systems in low-and middle-income countries. The study also didn’t clearly explain the involvement of the patient representative association, which makes it difficult to assess the degree of co-production in the guideline development process.
Lastly, as the author highlighted, the guidelines only reviewed the evidence for women due to a lack of evidence for men with PPD in the literature. It is a significant limitation of the guidelines and access to services for fathers experiencing PPD remains a great concern (Uriko et al., 2023).
These new guidelines for peripartum depression only included English studies and recommendations for women. Recommendations for fathers could not be made due to lack of evidence.
Implications for practice
As the review has shown, research on alternative interventions for prevention and treatment of PPD (physical activities, non-invasive brain treatment and peer support, etc.) is needed. Additionally, more evidence on consistent screening tools and timing is needed to inform the implementation of universal screening programmes. Other crucial areas of research include treatments of PPD among fathers and implementation of PPD interventions in healthcare systems in low-and-middle income countries.
In terms of clinical practice, the guidelines have shown the effectiveness of psychological interventions in prevention and treatment of PPD, especially CBT. Policy makers should widen the provision of psychological interventions within primary care or specialist mental health services which currently focus on medication treatment. Alternative interventions such as physical exercise have gathered a growing support from the evidence base. Physical exercises can be included as part of prevention or treatment package in healthcare services or promoted as a form of self-help for perinatal women.
Universal screening for PPD should be implemented in healthcare services given the positive evidence on its effectiveness in reducing depressive symptoms. As the authors suggested, policy makers should also ensure clear referral pathways for positive screening results ensuring that women with PPD are treated in a timely manner by trained professionals.
Psychological interventions and universal screening for peripartum depression should be adopted alongside more research on alternative interventions like exercise and peer support.
Statement of interests
Angelica Tong has no conflicts of interest to declare.
Edited by
Laura Hemming.
Links
Primary Paper
Sandra Nakić Radoš, Ana Ganho-Ávila, Maria F Rodriguez-Muñoz, Rena Bina Sarah Kittel-Schneider, Mijke P Lambregtse-van den Berg, Ilaria Lega, Angela Lupattelli, Greg Sheaf, Alkistis Skalkidou, Ana Uka, Susanne Uusitalo, Laurence Bosteels-Vanden Abeele, Mariana Moura-Ramos (2025). Evidence-based clinical practice guidelines for prevention, screening and treatment of peripartum depression. The British Journal of Psychiatry, 1-12.
Other References
Bauer, A, Knapp, M, Parsonage, M. Lifetime costs of perinatal anxiety and depression. J Affect Disord 2016; 192: 83–90.
Brouwers, M. C., Kho, M. E., Browman, G. P., Burgers, J. S., Cluzeau, F., Feder, G., … & Zitzelsberger, L. (2010). AGREE II: advancing guideline development, reporting and evaluation in health care. Cmaj, 182(18), E839-E842.
Schünemann H, Brożek J, Guyatt G, Oxman A, editors. GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, 2013.
Shea, B. J., Reeves, B. C., Wells, G., Thuku, M., Hamel, C., Moran, J., … & Henry, D. A. (2017). AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. bmj, 358.
Uriko, K., Cristoforou, A., Motrico, E., Moreno-Paral, P., Kömürcü Akik, B., Žutić, M., & Lambregtse-van den Berg, M. (2023). Paternal peripartum depression: Emerging issues and questions on prevention, diagnosis and treatment. Journal of psychosomatic obstetrics and gynecology, 44(S1), 6-6.
Yang, Y., Wang, T., Wang, D., Liu, M., Lun, S., Ma, S., & Yin, J. (2024). Gaps between current practice in perinatal depression screening and guideline recommendations: a systematic review. General hospital psychiatry, 89, 41-48.
