The perinatal period consists of pregnancy and one year after childbirth. It is associated with heightened risk of depression and anxiety in young people. This is because young people have to adjust to the demands of pregnancy and parenting while dealing with many psychological, biological and social risk factors associated with youth (Hodgkinson et al., 2014; Lara et al., 2012). It is estimated that worldwide 1 in 6 young women aged 25 and below experience perinatal depression and anxiety each year (Woody et al., 2017). Perinatal depression and anxiety can have detrimental effects on both maternal and child outcomes. For example, they can lead to poor parenting skills and poor mother-infant attachment. This in turn can negatively impact on the child’s cognitive, emotional, and social development (Barnet et al., 2008).

Considering these important aspects, Laurenzi and colleagues (2020) reviewed existing studies on psychosocial interventions targeting depression and anxiety in pregnant and parenting adolescents and explored their effectiveness. Psychosocial interventions refer to non-drug interventions comprising of different informational and psychological components. They focus on an individual’s psychological wellbeing in relation to their social environment. Examples include psychoeducation and cognitive behavioural therapy.

Methods

This study was conducted according to PRISMA guidelines (Moher et al., 2009).

The authors searched scientific databases specifically for randomised controlled trials (RCTs), cluster randomised trials, factorial trials and crossover trials conducted between 2000 and 2019. Reference lists for relevant articles and grey literature were also searched. Additionally, experts in the field were consulted.

To be included, interventions had to use any psychosocial approach with the following outcomes: (1) preventing depression and/or anxiety; (2) promoting positive mental health, and; (3) preventing self-injury and suicide. Other outcomes were considered, including school attendance, substance use, risky sexual and reproductive behaviour, parenting skills and adherence to antenatal and postnatal care.

Participants were pregnant and parenting adolescents aged 10-19. The included studies compared interventions to routine care. Studies that compared two active interventions were excluded.

Two reviewers independently assessed risk of bias and study quality using the Cochrane risk of bias tool. Grading Recommendations, Assessment, Development and Evaluation (GRADE) methodology was used to assess the quality of evidence. The meta-analysis combined outcome data across all time points with effect estimates being categorised according to the outcomes they represented and the length of follow-up. Standardised mean differences (SMD) were used to represent individual effect estimates. Variance estimation was used to account for multiple dependent effect estimates for each study. To account for heterogeneity in effectiveness, a meta-regression was done with categorical predictors to describe population and intervention characteristics.

Results

The review included 17 studies, and all of them were from high income countries (HICs). Most of the studies (n=15) were randomised controlled trials, one was a cluster randomised trial, and one a factorial trial design. The key findings were:

• There was a small to moderate effect of psychosocial interventions on positive mental health compared to routine care (SMD: 0.35, 95% CI: 0.10 to 0.61). Substantial statistical heterogeneity was identified. The quality of evidence was very low.
• The review found no beneficial effects of preventive psychosocial interventions among perinatal adolescents on symptoms and/or diagnoses of depression and anxiety (SMD: -0.11, 95% CI: -0.30 to 0.08). The quality of evidence was moderate.
• None of the included studies reported on self-harm or suicide.
• No significant effects were reported for other outcomes, such as substance use, risky sexual and reproductive behaviours, parenting skills and adherence to antenatal and postnatal care. There was moderate quality of evidence for parenting outcomes, low quality of evidence for adherence to antenatal and postnatal care, and very low quality of evidence for substance use and risky and reproductive behaviours.
• Psychosocial interventions showed a moderate to large beneficial effect on school attendance outcomes (SMD: 0.64, 95% CI: 0.55 to 0.72). No statistical heterogeneity was found. The quality of evidence was high.

Conclusions

In summary, Laurenzi et al. (2020) found that psychosocial interventions have small- to moderate-sized beneficial effects on positive mental health and school attendance for pregnant and parenting adolescents in high income countries. Considering that the conclusion on positive mental health was based on low quality evidence, the authors recommend that there is an urgent need for more high-quality evidence regarding the effectiveness of psychosocial interventions on mental health outcomes among adolescents in the perinatal period, especially in low- and middle-income countries (LMICs).

Strengths and limitations

• The methodology of the systematic review was rigorous in that it followed the PRISMA guidelines and systematically assessed the study quality. However, confidence in the quality of the evidence was generally low.
• Although the overall effect of any psychosocial interventions on various mental health outcomes was investigated, effects of different types of intervention on these outcomes remain unknown. It would be beneficial to explore whether specific types of interventions have different effects on mental health outcomes.
• All the included studies were from high income countries, so the generalisability of the results to low- and middle-income countries (LMICs) is limited.

Implications for practice

• The results of the review suggest that psychosocial interventions targeting adolescents in the perinatal period hold some promise for promoting positive mental health and improving school attendance.
• There is an urgent need for high quality evidence showing the effectiveness of different types of psychosocial interventions on mental outcomes among young people in the perinatal period, especially in low- and middle-income countries (LMICs).

Our Active Ingredients review – Psychoeducation for depression and anxiety in young parents

We were inspired by the study by Laurenzi et al. (2020) as it is one of the few reviews to investigate the effects of psychosocial interventions on a wide range of maternal outcomes, including depression and anxiety, specifically for young people in the perinatal period. For our Wellcome Trust funded active ingredients review, we decided to focus on psychoeducation.

Psychoeducation is the structured communication of information about mental health problems and how they can be prevented, treated, and/or managed. It is one of the most commonly used components in psychosocial interventions for perinatal mental health as well as other evidence-based psychotherapies (Chorpita & Daleiden, 2009). It can be delivered flexibly (i.e., group or individual), and across various settings (i.e., schools and clinics).

However, there is not much evidence for the use of psychoeducation interventions for youth perinatal depression and anxiety. Our review addressed the question: How, for whom, in what contexts, and why does psychoeducation work as an active ingredient for prevention and treatment of perinatal anxiety and depression in 14–24-year-olds?

To address the question, we triangulated evidence from three sources:

• A systematic review of quantitative studies that evaluated perinatal depression and anxiety outcomes in youth (14-24 years old);
• A thematic meta-synthesis of qualitative studies focusing on young people’s views about use, acceptability, facilitators, and barriers of using psychoeducation during pregnancy and postpartum;
• Discussions with an international Young Advisory Group (YAG) with lived experience of pregnancy before 25 years of age (n=12).

As part of the review, 8 quantitative studies were identified: 7 randomised controlled trials and one non-randomised trial.

• Two-thirds of the studies were from HICs such as USA and UK. The three studies from LMICS (Thailand, Kenya and Iran) all showed beneficial effects of the interventions on depression and anxiety.
• In one study, psychoeducation was offered as a standalone intervention. Seven studies were Multicomponent Interventions with Psychoeducation (MCIPs).
• Beneficial effects of the intervention were found in four out of 8 studies (2 MCIPs for depression, 1 MCIP for anxiety, and 1 standalone psychoeducation intervention for depression).
• All studies focused on postnatal outcomes, except one where outcomes were measured prenatally.
• There was limited evidence for anxiety (1 study).
• Psychoeducation works when delivered both individually or in groups, as well as in both short and longer interventions.

In addition, 12 qualitative studies were identified. Evidence from the qualitative studies, supported by the YAG suggested that psychoeducation works by increasing knowledge/awareness about anxiety and depression and relevant services available, as well as enhancing coping skills. This in turn leads to reduced stigma, improved self-recognition and management, and increased help-seeking. The YAG also suggested that psychoeducation interventions would be beneficial if offered in both the prenatal and postnatal periods, in a variety of formats and in a manner that is supportive and friendly.

Overall, we found that psychoeducation is an important active ingredient in interventions targeting perinatal depression and possibly anxiety, especially as a building block for other active ingredients. However, the evidence presented is not without limitations. Firstly, evidence on psychoeducation interventions targeting anxiety is limited. Secondly, none of the included studies measured factors that can modify the effect of psychoeducation. Lastly, none of the studies included young men. We suggest that researchers consider these gaps in future research.

Statement of interests

Wezi and Darya were part of the research team from the University of Sussex and the University of Malawi that received funding through the Wellcome Trust ‘Active Ingredients’ commission to conduct a review of psychoeducation as an active ingredient for preventing and/or treating perinatal depression and anxiety in youth. Wezi is also a recipient of the commonwealth scholarship for PhD study.

Links

Primary paper

Laurenzi, C. A., Gordon, S., Abrahams, N., et al. (2020). Psychosocial interventions targeting mental health in pregnant adolescents and adolescent parents: a systematic review. Reproductive Health, 17(1), 65.

Other references

Barnet, B., Liu, J. & Devoe, M. (2008). Double jeopardy: depressive symptoms and rapid subsequent pregnancy in adolescent mothers. Arch Pediatr Adolesc Med 162(3), 246-256

Chorpita,B. F., & Daleiden, E. L. (2009). Mapping evidence-based treatments for children and adolescents: application of the distillation and matching model to 615 treatments from 322 randomized trials. Journal of Consulting and Clinical Psychology, 77, 566-579

Hodgkinson, S., Beers, L., Southammakosane, C. & Lewin, A. (2013). Addressing the mental needs of pregnant and parenting adolescents. Paediatrics, 133(1), 114-122.

Lara, M. A., Berenzon, S., García, F. J., Medina-Mora, M. E., Rey, G. N., & Velázquez, J. A. V. (2012).Population study of depressive symptoms and risk factors in pregnant and parenting Mexican adolescents. Rev Panam Salud Publica,31(2), 102-108

Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Prisma Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Medicine, 6(7), e1000097

Woody, C. A., Ferrari, A. J., Siskind, D. J., Whiteford, H. A., & Harris, M. G. (2017). A systematic review and meta-regression of the prevalence and incidence of perinatal depression. Journal of Affective Disorders, 219, 86-92

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