Supportive counseling for postpartum depression in Asian mothers

O R I G I N A L A R T I C L E

Supportive counseling for postpartum depression in Asianmothers

Johnson Fam MBBS MMed (Psych), Helen Chen MBBS MMed (Psych) Dip Psychotherapy &Jemie Wang BPsych (Hons)

Mental Wellness Service, KK Women’s and Children’s Hospital, Singapore

Keywords

counseling, depression, postpartum

Correspondence

Johnson Fam, Mental Wellness Service, KK

Women’s and Children’s Hospital, Singapore,

100 Bukit Timah Road, 229899 Singapore.

Tel: 163 94 2205

Fax: 163 948 087

Email: [email protected]

Received 5 September 2010

Accepted 19 January 2011

DOI:10.1111/j.1758-5872.2011.00122.x

AbstractIntroduction: The aim of the present study was to describe the role of

supportive counseling for postpartum depression (PPD) in an Asian popu-

lation and explore the treatment outcomes of supportive counseling with

and without antidepressants. Oral antidepressants remain the mainstay

treatment in depression. However in postpartum depression, mothers are

often concerned about breastfeeding and the effects of medication on the

developing child. For mothers willing to take antidepressants, the class of

antidepressant more efficacious for postpartum depression still remains

unclear. Non-pharmacological treatments appear to have an important role

in recent studies.

Methods: In this naturalistic prospective cohort study, patients were iden-

tified from a postpartum depression screening program in a maternity

hospital. Patients diagnosed with PPD were treated with antidepressant and

counseling, or counseling alone. Outcomes were assessed using the Edin-

burgh Postnatal Depression Scale (EPDS) and Global Assessment of Func-

tioning Scale (GAF). Statistical Package for the Social Sciences (SPSS) was

used for statistical analyses (SPSS Inc., Chicago, IL, USA).

Results: Between April 2008 and December 2009, 87 patients were re-

cruited in this study. Sixty-nine percent of all patients achieved remission

at 6 months. Combining antidepressants and counseling did not appear to

significantly improve outcome compared to counseling alone.

Discussion: The majority of all depressed mothers with supportive coun-

seling had remission of symptoms by 6 months. The benefit of combining

antidepressants and counseling needs to be further studied.

Introduction

Maternal depression can have deleterious effects on

new mothers, their infants, and their family. Postpar-

tum mood disorders represent the most frequent form

of maternal morbidity following delivery (Stocky &

Lynch, 2000). A meta-analysis reported that approxi-

mately 13% of new mothers experience PPD in the

first year after childbirth (O’Hara & Swain, 1996). In

Singapore, a study of 559 women at 6 weeks postpar-

tum reported a point prevalence of 6.8% for depres-

sion (Chee et al., 2005).

Postpartum depression is not uncommon and

consequences can be grave, yet there remains a pau-

city of evidence for effective treatment, particularly of

randomized clinical trials on antidepressants use (Hoff-

brand et al., 2001). Mothers who breastfeed may be

apprehensive towards taking antidepressants, result-

ing in delayed treatment and illness progression. Anti-

depressants prescribed in reduced doses can also lead

to potentially ineffective treatment.

Psychosocial factors are important in the etiology

of postpartum depression, especially risk factors such

as stressful life events, marital conflict and the lack of

social support (O’Hara & Swain, 1996; Bernazzani

et al., 1997). Treatment by social and psychological

interventions appeared effective in a recent systematic

review and meta-analysis (Dennis & Hodnett, 2007).

In this study, we primarily aimed to examine the role

of supportive counseling for postpartum depression by

describing the characteristics of postpartum depressed

mothers, the treatment received and the longitudinal

Asia-Pacific Psychiatry 3 (2011) 61–66 Copyright c� 2011 Blackwell Publishing Asia Pty Ltd 61

Asia-Pacific Psychiatry ISSN 1758-5864

Offi cial journal of thePacifi c Rim College of Psychiatrists

mailto:[email protected]

outcome, and secondarily to explore if adding antide-

pressants affected treatment outcome.

Methods

Study design

Naturalistic prospective cohort study.

Participants

Participants were recruited consecutively from general

obstetric outpatient clinics from the largest hospital

providing specialized obstetric and care in Singapore,

under a postpartum depression screening and inter-

vention program.

Inclusion criteria

(i) All women screened within 6 months after a live

birth.

(ii) Baseline Edinburgh Postnatal Depression Scale

(EPDS) score Z13, and with follow-up score.

(iii) Clinically assessed to have major or minor depres-

sion according to Diagnostic and Statistical Manual of

Mental Diseases Fourth Edition (DSM-IV) Research

Criteria.

Exclusion criteria

(i) Young mothers aged below 18, as they are already

provided care from an established medical social work

program that includes emotional support.

(ii) Mothers who were already engaged in psychiatric

care during the antepartum period.

Screening procedure

Participants were screened by trained perinatal mental

health case managers, in a private setting, using the

EPDS (Cox et al., 1987). We made a minor modification

to the EPDS, to include the qualifier of symptoms ‘‘in

the past 1 week’’, as in a pilot run we noted that local

women tended to misinterpret the questions to refer-

ring to the general past. We used a threshold of 13 to

identify women likely to suffer from major depression,

as recommended (Cox et al., 1987; Murray & Car-

others, 1990). Those with EPDS scores of 13 or more

were clinically reviewed to confirm diagnosis accord-

ing to DSM-IV.

Intervention

Treatment was provided to cases identified to have

postpartum depression after initial screening and clin-

ical assessment by a psychiatrist. Clinical intervention

included supportive counseling and antidepressants,

or supportive counseling alone. Supportive counseling

is given to all patients by both clinicians and case

managers, addressing the immediate stressors, particu-

larly those relating to the adjustment to motherhood

and the newborn. It is given during follow-up visits

and telephone contact. A supportive counseling frame-

work, detailing areas to address during initial, follow-

up and concluding sessions, was in place to provide

both guidance and consistency.

Antidepressants were given to patients who were

agreeable to take medications. The type of antidepres-

sant used was in accordance with UK guidelines

(National Institute for Health and Clinical Excellence,

2007), and by considering individual patient risk

and their informed choice of either tricyclic antide-

pressants (TCAs) or selective serotonin reuptake inhi-

bitors (SSRIs).

Case management was provided by trained case

managers, providing integrated and individualized

care for our patients together with the psychiatrist,

thus ensuring continuity of care through the different

phases of the illness. To enhance the level of social

support, participation in facilitated support groups was

encouraged. Those with significant social problems

(e.g. domestic violence, marital conflicts, and financial

difficulties) were referred to our medical social work-

ers or appropriate community resources.

Outcome measurement

The EPDS and Global Assessment of Functioning

Scale (GAF) scores were measured at baseline, and

subsequently measured again upon discharge, or by

6 months follow-up if not discharged. The EPDS

is validated in many Asian populations (Lee et al.,

1998; Rushidi et al., 2002; Benjamin et al., 2005)

and has been used to measure change in postnatal

depression. The reliable change index (RCI) using

12/13 as the cutoff for depression was calculated to be

4 points for 95% confidence in detecting real change

(Matthey, 2004). Remission was defined as o9 points

on follow-up EPDS score. Time to remission was

measured in weeks.

Data analysis

Statistical Package for the Social Sciences (SPSS) ver-

sion 14 (SPSS Inc., Chicago, IL, USA) was used for data

analysis unless otherwise stated. The t-test, w2 and

analysis of variance (ANOVA) were used where appro-

priate for univariate analysis. Regression methods

were used for covariate analysis.

62 Asia-Pacific Psychiatry 3 (2011) 61–66 Copyright c� 2011 Blackwell Publishing Asia Pty Ltd

J. Fam et al.Counseling for postpartum depression in Asian mothers

Results

From April 2008 to December 2009, 87 subjects who

met the study criteria received psychiatric treatment at

KK Hospital. Of the 12 lost to follow-up, nine were not

contactable, one refused for no reason, one refused for

financial reason and one returned overseas. The over-

all drop-out rate in this study was low at 13.8%.

Comparing those who accepted treatment and

those lost to follow-up, no significant statistical differ-

ence was found for race, education, marital status,

number of children, baseline EPDS score, percentage

of major depressives and treatment given. However,

subjects lost to follow-up were significantly younger

by an average of 3 years. Post-baseline assessment was

not obtained for those lost to follow-up.

For patients who received antidepressants, 54%

were on TCAs and 46% on SSRIs (Figure 1). TCAs

were used at the lower end of the therapeutic range

compared to the SSRIs (Figure 2), due to the side-effect

tolerability of TCAs.

Baseline depression scores and proportion of sub-

jects with major depression were similar in the three

groups (Table 1). There were significantly fewer In-

dians and tertiary educated subjects in the SSRI group,

and the TCA group subjects were diagnosed earlier.

These variables were adjusted for during outcome

analysis. Twenty percent of all subjects had psychiatric

comorbidities, most frequently an anxiety disorder. Se-

venty-three percent had domestic help in the form of a

live-in maid, relative or some childcare arrangement.

The most prominent psychosocial stressor was marital

problems, affecting 36% of all depressed women.

In Table 2, no significant differences in treatment

outcomes were found among the three groups. Cov-

ariate adjusted post-treatment scores similarly did not

show statistical difference.

The total proportion of remissions at 6 months

were 72% in the TCA and counseling group, 52% in

the SSRI and counseling group and 86% in the coun-

seling alone group. The differences did not reach

statistical difference (P = 0.055), even after adjusting

for covariates. The overall remission for all patients,

regardless of treatment type, was 69% at 6 months.

Among patients who remitted, those on SSRIs and

counseling appeared to take longer to remit compared to

the other two groups, but this was not statistically

significant (Table 3). After adjusting for covariates, there

were still no significant differences in the time to remis-

sion. The mean time to remission was 7.4 weeks.

Discussion

This naturalistic study examined the treatment of post-

natal depression in an outpatient setting of a maternity

hospital. We sought to explore the role of supportive

counseling in a realistic setting and on an Asian popula-

tion, and to examine the treatment outcomes.

In this study, 86% of mothers who received sup-

portive counseling alone had remission, and those

who remitted did so at around 7 weeks. From epide-

miological studies, episodes of postnatal depression last

3 to 6 months (Cooper & Murray, 1995) and up to 50%

of mothers remain depressed at 6 months, and around

25% continue to remain depressed at 1 year postpar-

tum (Kumar & Robson, 1984). From our results, it

appears that supportive counseling was improving

patients’ outcome above that of natural remission.

Whether this benefit is sustained in the long term

requires further study (Cooper et al., 2003).

Seventy-two percent of women diagnosed with

postpartum depression in our study agreed to be on

antidepressant therapy. This perhaps reflects the chan-

ging trend in patient acceptance of medication use in

postpartum depression.

It was striking to observe that antidepressant use

in this study did not result in a larger improvement or a

faster time to remission. The use of lower TCA dosages

compared to SSRIs did not appear to have a differential

effect on treatment outcome. Systematic review of

46%

8%

24%

15%7%

Antidepressants

Dothiepin

Clomipramine

Sertraline

Escitalopram

Fluoxetine

Figure 1 Antidepressants prescribed.

Figure 2 Antidepressant dosages.


J. Fam et al. Counseling for postpartum depression in Asian mothers

randomized controlled trials that compared low dosage

tricyclics with placebo, and low dosage tricyclics with

standard dosage tricyclics, found that low dosage tri-

cyclics were 1.65 and 1.47 times more likely than

placebo to bring about response at 4 weeks and 6 to 8

weeks, respectively (Furukawa et al., 2003). Standard

dosage tricyclics, however, failed to bring about more

response but produced more dropouts due to side-

effects compared to low dosage tricyclics (Furukawa

et al., 2003).

Table 1. Baseline characteristics (treatment groups)

TCA1Counsel SSRI1Counsel Counseling

P-value(n = 29) (n = 25) (n = 21)

Age, years� 33.6 (4.5)� 33.2 (4.7)� 31.8 (4.7)� 0.392

Race (%)

Chinese 58.6 76.0 66.7 0.402

Malay 10.3 16.0 4.8 0.515

Indian 24.1 4.0 23.8 0.075

Other 6.9 4.0 4.8 1.000

Education (%)

Tertiary/degree 79.3 52.0 81.0 0.042

Secondary/vocational 20.7 44.0 19.0 0.116

Primary 0.0 4.0 0.0 0.613

Marital status (%)

Married 100 100 95.2 0.280

No. children (%) (antepartum)

Nil 48.3 56.0 61.9 0.625

1 24.1 28.0 33.3 0.775

2 or more 27.6 16.0 4.8 0.105

Baseline EPDS score� 18.7 (3.4)� 20.4 (3.3)� 19.0 (4.8)� 0.227

Baseline GAF score� 57.5 (6.4)� 56.3 (7.1)� 59.4 (8.7)� 0.361

Major depression (%) 72.4 80.0 52.4 0.116

Postnatal week diagnosed� 7.8 (3.6)� 16.5 (14.9)� 14.2 (13.7)� 0.019

Psychiatric comorbidity (%) 13.8 20.0 28.6 0.449

Domestic help (%) 65.5 84.0 71.4 0.312

Marital problem (%) 37.9 28.0 42.9 0.557

Financial problem (%) 17.2 8.0 9.5 0.667

Work problem (%) 6.9 28.0 9.5 0.095

�Data shown as mean (standard error).

EPDS, Edinburgh Postnatal Depression Scale; GAF, Global Assessment of Functioning Scale; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic

antidepressant.

Table 2. Edinburgh Postnatal Depression Scale (EPDS) and Global Assessment of Functioning Scale (GAF) scores�


P-value(n = 29) (n = 25) (n = 21)

Change EPDS score 13.2 (0.7) 12.5 (1.4) 14.0 (0.9) 0.645

Change GAF score 23.2 (2.4) 21.5 (2.8) 21.2 (2.1) 0.823

Adjusted post-treatment EPDS score 6.6 (1.0) 6.8 (1.1) 5.0 (1.1) 0.476

Adjusted post-treatment GAF score 79.9 (1.9) 79.4 (2.1) 80.9 (2.0) 0.881


SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant.

Table 3. Time to remission�


P-value(n = 21) (n = 13) (n = 18)

Time to remission, weeks 7.0 (1.1) 9.2 (1.5) 6.8 (1.4) 0.430

Adjusted time to remission, weeks 8.6 (1.3) 6.8 (1.8) 6.5 (1.3) 0.547




In a meta-analysis of randomized controlled trials

of antidepressants in general, using patient-level data,

it was found that the magnitude of benefit from

antidepressant medication compared with placebo in-

creased with severity of depression symptoms, and

may be minimal in patients with mild or moderate

depression symptoms (Fournier et al., 2010). It may be

possible that the antidepressant effect may have failed

to separate from the counseling effect because of the

moderate levels of depression in our cohort. Another

postulation is that the women who opted for counsel-

ing and declined antidepressants were more resilient,

and psychologically minded. Indeed, baseline educa-

tion for the counseling alone group was observed to be

higher than the antidepressant combination groups.

To our knowledge, there are no published controlled

trials comparing supportive counseling with antidepres-

sant treatment in postpartum depression. One rando-

mized controlled trail compared fluoxetine plus cognitive

behavioral counseling (CBC) with placebo plus CBC

(Appleby et al., 1997). Fluoxetine and a full course of

CBC combined had no added advantage over placebo

and a full course CBC. Although this lends some support

to our observation, there is still a need to see if our result

could be replicated in a larger, randomized controlled

trial using supportive counseling in place of CBC.

Considering the study limits, these findings may

not be conclusive and need further verification. Never-

theless, our results do provide useful pilot data to

suggest that supportive counseling alone may be ade-

quate for mothers with depression that is mild to

moderate in severity.

Conclusion

With the coordinated care and close monitoring from

case managers, the overall drop-out from treatment was

low. Sixty-nine percent of all depressed mothers on their

preferred treatment had remission of symptoms by 6

months, within an average time of 7 weeks. Mothers

allowed to express treatment preference may benefit

overall outcome.

Within the limitations of this study, we observed

no additional benefit combining antidepressants with

supportive counseling for mild to moderate levels of

depression. The evidence is inconclusive and more

trials are needed in this area before clinical recommen-

dations can be made.

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Supportive counseling for postpartum depression in Asian mothers