Non-Pharmacological Strategies for Postpartum Depression: A Network Meta-Analysis of Randomized Controlled Trials
-
Hilmi Amirul Haq
,
Zainab Khalisah Nurulhaq
,
Bryan Naufal Abdullah
,
Siti Wahyuni
,
Farida Murtiani
,
Rahmat Saputra
Abstract
Objective: Postpartum depression (PPD) has a significant impact on the mother, child and family. Pharmacologic therapy in breastfeeding mothers often causes side effects, so non-pharmacologic alternatives are needed. This study aims to systematically review and synthesize evidence from randomized controlled trials (RCTs) on the effectiveness of non-pharmacological interventions for PPD through a network meta-analysis.
Method: This network meta-analysis synthesizes evidence from RCTs evaluating non-pharmacological interventions for PPD. We reviewed 13 articles from PubMed, Science Direct, Scopus, and Cochrane Library. Network Meta-Analysis was performed using RStudio with a random effects model, while Rob 2.0, RoB-ME, and CINeMA were used to assess the risk of bias.
Results: The analysis showed that Therapy-Assisted Internet Cognitive Behavioral Therapy (TA-iCBT) had the highest benefit with a Mean Difference (MD) of 6.90 [95% CI 5.35 to 8.45], p = 0.005, as well as the highest effectiveness (P-score 0.891) and very low heterogeneity (I² = 0%). Qualitatively, other alternative therapies are also safe for the mother, but need to be tailored to the patient's needs.
Conclusion: In conclusion, TA-iCBT is the most effective non-pharmacological therapy for PPD and can be the main choice in the psychiatric treatment of PPD patients.
Organization WH. Report of the second meeting of the Strategic and Technical Advisory Group for Mental Health, Brain Health and Substance Use: World Health Organization; 2023.
2. Stewart DE, Vigod SN. Postpartum depression: pathophysiology, treatment, and emerging therapeutics. Annu Rev Med. 2019;70(1):183-96.
3. Adli FK. Edinburgh Post-natal Depression Scale (EPDS): Deteksi Dini dan Skrining Depresi Post-partum. Jurnal Kesehatan. 2022;13(2):430-6.
4. Puspitasari R, Haryanti P. The Relationship between anxiety, depression, and vital signs among postpartum mothers in Yogyakarta. 2021.
5. Guille C, Newman R, Fryml LD, Lifton CK, Epperson CN. Management of postpartum depression. J Midwifery Womens Health. 2013;58(6):643-53.
6. Khoirunnisa K, Sintia Y, Nurhafifah S, Jati BIM, Rahmawati S, Kurniawan K. Intervensi Non-Farmakologi untuk Mengurangi Nyeri Haid pada Remaja: Narrative Review. Jurnal Ilmiah Permas: Jurnal Ilmiah STIKES Kendal. 2023;13(3):917-26.
7. Gkintoni E, Vassilopoulos SP, Nikolaou G. Next-Generation Cognitive-Behavioral Therapy for Depression: Integrating Digital Tools, Teletherapy, and Personalization for Enhanced Mental Health Outcomes. Medicina (Kaunas) [Internet]. 2025 Mar 1 [cited 2025 Nov 3];61(3). Available from: https://pubmed.ncbi.nlm.nih.gov/40142242/
8. Goodman JH. Women's attitudes, preferences, and perceived barriers to treatment for perinatal depression. Birth. 2009;36(1):60-9.
9. Sockol LE. A systematic review and meta-analysis of interpersonal psychotherapy for perinatal women. J Affect Disord. 2018;232:316-28.
10. Shorey S, Chee CYI, Ng ED, Chan YH, San Tam WW, Chong YS. Prevalence and incidence of postpartum depression among healthy mothers: A systematic review and meta-analysis. J Psychiatr Res. 2018;104:235-48.
11. JPTTJ H, Chandler J, Cumpston M, Li T, Page M, Welch V. cochrane handbook for systematic reviews of interventions version 6.4 (updated August 2023). cochrane, 2023. 2024.
12. Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron C, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med. 2015;162(11):777-84.
13. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-6.
14. Matthey S, Henshaw C, Elliott S, Barnett B. Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale: implications for clinical and research practice. Arch Womens Ment Health. 2006;9(6):309-15.
15. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. Bmj. 2019;366:l4898.
16. McGuinness LA, Higgins JPT. Risk-of-bias VISualization (robvis): An R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods. 2021;12(1):55-61.
17. Balduzzi S, Rücker G, Nikolakopoulou A, Papakonstantinou T, Salanti G, Efthimiou O, et al. netmeta: an R package for network meta-analysis using frequentist methods. J Stat Softw. 2023;106:1-40.
18. Balduzzi S, Rücker G, Schwarzer G. How to perform a meta-analysis with R: a practical tutorial. Evid Based Ment Health. 2019;22(4):153-60.
19. Chabrol H, Teissedre F, Saint-Jean M, Teisseyre N, Roge B, Mullet E. Prevention and treatment of post-partum depression: a controlled randomized study on women at risk. Psychol Med. 2002;32(6):1039-47.
20. Heh SS, Huang LH, Ho SM, Fu YY, Wang LL. Effectiveness of an exercise support program in reducing the severity of postnatal depression in Taiwanese women. Birth. 2008;35(1):60-5.
21. Dennis C-L, Hodnett E, Kenton L, Weston J, Zupancic J, Stewart DE, et al. Effect of peer support on prevention of postnatal depression among high risk women: multisite randomised controlled trial. Bmj. 2009;338.
22. Gao L-l, Chan SW-c, Li X, Chen S, Hao Y. Evaluation of an interpersonal-psychotherapy-oriented childbirth education programme for Chinese first-time childbearing women: a randomised controlled trial. Int J Nurs Stud. 2010;47(10):1208-16.
23. O'Mahen HA, Woodford J, McGinley J, Warren FC, Richards DA, Lynch TR, et al. Internet-based behavioral activation—Treatment for postnatal depression (Netmums): A randomized controlled trial. J Affect Disord. 2013;150(3):814-22.
24. Hou Y, Hu P, Zhang Y, Lu Q, Wang D, Yin L, et al. Cognitive behavioral therapy in combination with systemic family therapy improves mild to moderate postpartum depression. Braz J Psychiatry. 2014;36(1):47-52.
25. Ngai FW, Wong PW, Leung KY, Chau PH, Chung KF. The Effect of Telephone-Based Cognitive-Behavioral Therapy on Postnatal Depression: A Randomized Controlled Trial. Psychother Psychosom. 2015;84(5):294-303.
26. Leung SS, Lee AM, Wong DF, Wong CM, Leung KY, Chiang VC, et al. A brief group intervention using a cognitive-behavioural approach to reduce postnatal depressive symptoms: a randomised controlled trial. Hong Kong Med J. 2016;22 Suppl 2:S4-8.
27. Daley AJ, Jolly K, Sharp DJ, Turner KM, Blamey RV, Coleman S, et al. The effectiveness of exercise as a treatment for postnatal depression: study protocol. BMC Pregnancy Childbirth. 2012;12(1):45.
28. Pugh NE, Hadjistavropoulos HD, Dirkse D. A Randomised Controlled Trial of Therapist-Assisted, Internet-Delivered Cognitive Behavior Therapy for Women with Maternal Depression. PLoS One. 2016;11(3):e0149186.
29. Jannati N, Mazhari S, Ahmadian L, Mirzaee M. Effectiveness of an app-based cognitive behavioral therapy program for postpartum depression in primary care: A randomized controlled trial. International Journal of Medical Informatics. 2020;141:104145.
30. Lewis BA, Schuver K, Dunsiger S, Samson L, Frayeh AL, Terrell CA, et al. Randomized trial examining the effect of exercise and wellness interventions on preventing postpartum depression and perceived stress. BMC Pregnancy Childbirth. 2021;21(1):785.
31. Babiy Z, Layton H, Savoy CD, Xie F, Brown JS, Bieling PJ, et al. One-day peer-delivered cognitive behavioral therapy-based workshops for postpartum depression: A randomized controlled trial. Psychother Psychosom. 2024;93(2):129-40.
32. Lewis BA, Schuver K, Dunsiger S, Samson L, Frayeh AL, Terrell CA, et al. Randomized trial examining the effect of exercise and wellness interventions on preventing postpartum depression and perceived stress. BMC Pregnancy Childbirth. 2021;21(1):785.
33. Salkovskis PM, Sighvatsson MB, Sigurdsson JF. How effective psychological treatments work: mechanisms of change in cognitive behavioural therapy and beyond. Behav Cogn Psychother. 2023;51(6):595-615.
34. Payne JL, Maguire J. Pathophysiological mechanisms implicated in postpartum depression. Front Neuroendocrinol. 2019;52:165-80.
35. Headon KS. The Association between Air Pollution Exposure and the Risk of Postpartum Depression and Gestational Diabetes Mellitus during the COVID-19 Pandemic: University of California, Irvine; 2024.
36. Zeng G, Niu J, Zhu K, Li F, Li L, Gao K, et al. Effects of non-pharmacological interventions on depressive and anxiety symptoms in pregnant women: a systematic review and network meta-analysis. EClinicalMedicine. 2025;79:103011.
37. Alloghani MM, Baig MR, Alawadhi SMS. Sociodemographic correlates of postpartum depression: A survey-based study. Iran J Psychiatry. 2024;19(2):174.
2. Stewart DE, Vigod SN. Postpartum depression: pathophysiology, treatment, and emerging therapeutics. Annu Rev Med. 2019;70(1):183-96.
3. Adli FK. Edinburgh Post-natal Depression Scale (EPDS): Deteksi Dini dan Skrining Depresi Post-partum. Jurnal Kesehatan. 2022;13(2):430-6.
4. Puspitasari R, Haryanti P. The Relationship between anxiety, depression, and vital signs among postpartum mothers in Yogyakarta. 2021.
5. Guille C, Newman R, Fryml LD, Lifton CK, Epperson CN. Management of postpartum depression. J Midwifery Womens Health. 2013;58(6):643-53.
6. Khoirunnisa K, Sintia Y, Nurhafifah S, Jati BIM, Rahmawati S, Kurniawan K. Intervensi Non-Farmakologi untuk Mengurangi Nyeri Haid pada Remaja: Narrative Review. Jurnal Ilmiah Permas: Jurnal Ilmiah STIKES Kendal. 2023;13(3):917-26.
7. Gkintoni E, Vassilopoulos SP, Nikolaou G. Next-Generation Cognitive-Behavioral Therapy for Depression: Integrating Digital Tools, Teletherapy, and Personalization for Enhanced Mental Health Outcomes. Medicina (Kaunas) [Internet]. 2025 Mar 1 [cited 2025 Nov 3];61(3). Available from: https://pubmed.ncbi.nlm.nih.gov/40142242/
8. Goodman JH. Women's attitudes, preferences, and perceived barriers to treatment for perinatal depression. Birth. 2009;36(1):60-9.
9. Sockol LE. A systematic review and meta-analysis of interpersonal psychotherapy for perinatal women. J Affect Disord. 2018;232:316-28.
10. Shorey S, Chee CYI, Ng ED, Chan YH, San Tam WW, Chong YS. Prevalence and incidence of postpartum depression among healthy mothers: A systematic review and meta-analysis. J Psychiatr Res. 2018;104:235-48.
11. JPTTJ H, Chandler J, Cumpston M, Li T, Page M, Welch V. cochrane handbook for systematic reviews of interventions version 6.4 (updated August 2023). cochrane, 2023. 2024.
12. Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron C, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med. 2015;162(11):777-84.
13. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-6.
14. Matthey S, Henshaw C, Elliott S, Barnett B. Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale: implications for clinical and research practice. Arch Womens Ment Health. 2006;9(6):309-15.
15. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. Bmj. 2019;366:l4898.
16. McGuinness LA, Higgins JPT. Risk-of-bias VISualization (robvis): An R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods. 2021;12(1):55-61.
17. Balduzzi S, Rücker G, Nikolakopoulou A, Papakonstantinou T, Salanti G, Efthimiou O, et al. netmeta: an R package for network meta-analysis using frequentist methods. J Stat Softw. 2023;106:1-40.
18. Balduzzi S, Rücker G, Schwarzer G. How to perform a meta-analysis with R: a practical tutorial. Evid Based Ment Health. 2019;22(4):153-60.
19. Chabrol H, Teissedre F, Saint-Jean M, Teisseyre N, Roge B, Mullet E. Prevention and treatment of post-partum depression: a controlled randomized study on women at risk. Psychol Med. 2002;32(6):1039-47.
20. Heh SS, Huang LH, Ho SM, Fu YY, Wang LL. Effectiveness of an exercise support program in reducing the severity of postnatal depression in Taiwanese women. Birth. 2008;35(1):60-5.
21. Dennis C-L, Hodnett E, Kenton L, Weston J, Zupancic J, Stewart DE, et al. Effect of peer support on prevention of postnatal depression among high risk women: multisite randomised controlled trial. Bmj. 2009;338.
22. Gao L-l, Chan SW-c, Li X, Chen S, Hao Y. Evaluation of an interpersonal-psychotherapy-oriented childbirth education programme for Chinese first-time childbearing women: a randomised controlled trial. Int J Nurs Stud. 2010;47(10):1208-16.
23. O'Mahen HA, Woodford J, McGinley J, Warren FC, Richards DA, Lynch TR, et al. Internet-based behavioral activation—Treatment for postnatal depression (Netmums): A randomized controlled trial. J Affect Disord. 2013;150(3):814-22.
24. Hou Y, Hu P, Zhang Y, Lu Q, Wang D, Yin L, et al. Cognitive behavioral therapy in combination with systemic family therapy improves mild to moderate postpartum depression. Braz J Psychiatry. 2014;36(1):47-52.
25. Ngai FW, Wong PW, Leung KY, Chau PH, Chung KF. The Effect of Telephone-Based Cognitive-Behavioral Therapy on Postnatal Depression: A Randomized Controlled Trial. Psychother Psychosom. 2015;84(5):294-303.
26. Leung SS, Lee AM, Wong DF, Wong CM, Leung KY, Chiang VC, et al. A brief group intervention using a cognitive-behavioural approach to reduce postnatal depressive symptoms: a randomised controlled trial. Hong Kong Med J. 2016;22 Suppl 2:S4-8.
27. Daley AJ, Jolly K, Sharp DJ, Turner KM, Blamey RV, Coleman S, et al. The effectiveness of exercise as a treatment for postnatal depression: study protocol. BMC Pregnancy Childbirth. 2012;12(1):45.
28. Pugh NE, Hadjistavropoulos HD, Dirkse D. A Randomised Controlled Trial of Therapist-Assisted, Internet-Delivered Cognitive Behavior Therapy for Women with Maternal Depression. PLoS One. 2016;11(3):e0149186.
29. Jannati N, Mazhari S, Ahmadian L, Mirzaee M. Effectiveness of an app-based cognitive behavioral therapy program for postpartum depression in primary care: A randomized controlled trial. International Journal of Medical Informatics. 2020;141:104145.
30. Lewis BA, Schuver K, Dunsiger S, Samson L, Frayeh AL, Terrell CA, et al. Randomized trial examining the effect of exercise and wellness interventions on preventing postpartum depression and perceived stress. BMC Pregnancy Childbirth. 2021;21(1):785.
31. Babiy Z, Layton H, Savoy CD, Xie F, Brown JS, Bieling PJ, et al. One-day peer-delivered cognitive behavioral therapy-based workshops for postpartum depression: A randomized controlled trial. Psychother Psychosom. 2024;93(2):129-40.
32. Lewis BA, Schuver K, Dunsiger S, Samson L, Frayeh AL, Terrell CA, et al. Randomized trial examining the effect of exercise and wellness interventions on preventing postpartum depression and perceived stress. BMC Pregnancy Childbirth. 2021;21(1):785.
33. Salkovskis PM, Sighvatsson MB, Sigurdsson JF. How effective psychological treatments work: mechanisms of change in cognitive behavioural therapy and beyond. Behav Cogn Psychother. 2023;51(6):595-615.
34. Payne JL, Maguire J. Pathophysiological mechanisms implicated in postpartum depression. Front Neuroendocrinol. 2019;52:165-80.
35. Headon KS. The Association between Air Pollution Exposure and the Risk of Postpartum Depression and Gestational Diabetes Mellitus during the COVID-19 Pandemic: University of California, Irvine; 2024.
36. Zeng G, Niu J, Zhu K, Li F, Li L, Gao K, et al. Effects of non-pharmacological interventions on depressive and anxiety symptoms in pregnant women: a systematic review and network meta-analysis. EClinicalMedicine. 2025;79:103011.
37. Alloghani MM, Baig MR, Alawadhi SMS. Sociodemographic correlates of postpartum depression: A survey-based study. Iran J Psychiatry. 2024;19(2):174.
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| Depression Edinburgh Postnatal Depression Scale (EPDS) Network Meta-Analysis Postpartum Psychotherapy | ||
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How to Cite
1.
Amirul Haq H, Khalisah Nurulhaq Z, Naufal Abdullah B, Wahyuni S, Murtiani F, Saputra R. Non-Pharmacological Strategies for Postpartum Depression: A Network Meta-Analysis of Randomized Controlled Trials. Iran J Psychiatry. 2025;:1-11.
