Psychological Medicine

  • Psychological Medicine / Volume 41 / Issue 04 / April 2011, pp 739-748
  • Copyright © Cambridge University Press 2010. The online version of this article is published within an Open Access environment subject to the conditions of the Creative Commons Attribution-NonCommercial-ShareAlike licence <>. The written permission of Cambridge University Press must be obtained for commercial re-use.
  • DOI: (About DOI), Published online: 18 August 2010

Original Articles

Universal prevention of depression in women postnatally: cluster randomized trial evidence in primary care

T. S. Brughaa1 c1, C. J. Morrella2, P. Sladea3 and S. J. Waltersa4

a1 Clinical Division of Psychiatry, Department of Health Sciences, University of Leicester, Leicester, UK

a2 School of Nursing, Faculty of Medicine and Health Sciences, Midwifery and Physiotherapy, University of Nottingham, Nottingham, UK

a3 Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK

a4 Medical Statistics Group, School of Health and Related Research, University of Sheffield, Sheffield, UK


Background To test whether receiving care from a health visitor (HV) trained in identification and psychological intervention methods prevents depression 6–18 months postnatally in women who are not depressed 6 weeks postnatally.

Method The study was a prospective cluster trial, randomized by GP practice, with follow-up for 18 months in 101 primary care teams in the Trent area of England. The participants were women scoring <12 on the postal Edinburgh Postnatal Depression Scale (EPDS) at 6 weeks postnatally (1474 intervention and 767 control women). Intervention HVs (n=89, 63 clusters) were trained in identifying depressive symptoms using the EPDS and face-to-face clinical assessment and in providing psychologically orientated sessions based on cognitive behavioral or person-centered principles. The control group comprised HVs (n=49, 37 clusters) providing care as usual (CAU). The primary outcome measure was the proportion of women scoring ≥12 on the EPDS at 6 months postnatally. Secondary outcomes were mean EPDS score, Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM) score, State–Trait Anxiety Inventory (STAI), 12-item Short Form Health Survey (SF-12) and Parenting Stress Index Short Form (PSI-SF) scores at 6, 12 and 18 months.

Results After adjusting for individual-level covariates, living alone, previous postnatal depression (PND), the presence of one or more adverse life events and the 6-week EPDS score, the odds ratio (OR) for EPDS ≥12 at 6 months was 0.71 [95% confidence interval (CI) 0.53–0.97, p=0.031] for the intervention group (IG) women compared with the control (CAU) group women. Two subgroups were formed by baseline severity: a ‘subthreshold’ subgroup with a 6-week EPDS score of 6–11 (n=999) and a ‘lowest severity’ subgroup with a 6-week EPDS score of 0–5 (n=1242). There was no difference in psychological effectiveness by subgroup (interaction term: z=−0.28, p=0.782).

Conclusions This study provides new evidence of a universal, enduring preventive effect for depression in women who screen negative for depression postnatally.

(Received March 02 2009)

(Revised June 09 2010)

(Accepted July 02 2010)

(Online publication August 18 2010)


c1 Address for correspondence: Professor T. S. Brugha, M.D. (N.U.I.), F.R.C. Psych., Department of Health Sciences, University of Leicester, Leicester General Hospital, Leicester LE5 4PW, UK. (Email: