HV training was effective compared with HV usual care in reducing the proportion of at-risk women with a 6-month EPDS score > or = 12, with a wide confidence interval for the estimated intervention effect, suggesting that the true treatment effect may be small. The effect remained for 1 year. The economic evaluation demonstrated that the HV intervention was highly likely to be cost-effective compared with the control. There was no difference in outcomes between the CBA and the PCA groups.

Objective To evaluate benefits for postnatal women of two psychologically informed interventions by health visitors. Design Prospective cluster trial randomised by general practice, with 18 month follow-up. Setting 101 general practices in Trent, England. Participants 2749 women allocated to intervention, 1335 to control. Intervention Health visitors (n=89 63 clusters) were trained to identify depressive symptoms at six to eight weeks postnatally using the Edinburgh postnatal depression scale (EPDS) and clinical assessment and also trained in providing psychologically informed sessions based on cognitive behavioural or person centred principles for an hour a week for eight weeks. Health visitors in the control group (n=49 38 clusters) provided usual care. Main outcome measures Score ≥12 on the Edinburgh postnatal depression scale at six months. Secondary outcomes were mean Edinburgh postnatal depression scale, clinical outcomes in routine evaluation-outcome measure (CORE-OM), state-trait anxiety inventory (STAI), SF-12, and parenting stress index short form (PSI-SF) scores at six, 12, 18 months. Results 4084 eligible women consented and 595 women had a six week EPDS score ≥12. Of these, 418 had EPDS scores available at six weeks and six months. At six months, 34% women (93/271) in the intervention group and 46% (67/147) in the control group had an EPDS score ≥12. The odds ratio for score ≥12 at six months was 0.62 (95% confidence interval 0.40 to 0.97, P=0.036) for women in the intervention group compared with women in the control group. After adjustment for covariates, the odds ratio was 0.60 (0.38 to 0.95, P=0.028). At six months, 12.4% (234/1880) of all women in the intervention group and 16.7% (166/995) of all women in the control group had scores ≥12 (0.67, 0.51 to 0.87, P=0.003). Benefit for women in the intervention group with a six week EPDS score ≥12 and for all women was maintained at 12 months postnatally. There was no differential benefit for either psychological approach over the other. Conclusion Training health visitors to assess women, identify symptoms of postnatal depression, and deliver psychologically informed sessions was clinically effective at six and 12 months postnatally compared with usual care. Trial registration ISRCTN92195776. INTRODUCTIONPostnatal depression is a global problem and an important public health issue. About 13% of women experience depression during the first postnatal year, 1 yet there are problems in recognition because its clinical assessment is complex. There can be serious consequences for the mother, her child, 2 and family and a risk of suicide (the leading cause of maternal death in England and Wales) and infanticide in some severely depressed mothers.3 Fathers are also more likely to be depressed if their partner is depressed, 4 and the children of fathers who experience depression in the postnatal period are at increased risk of behaviour problems. 5In primary care, psychological interventions are as clinically effective in the management of depression...

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Although a direct aetiological role for these risk factors is not certain, they may indicate strategies for the prevention of affective morbidity in postnatal women. These may include reducing unwanted pregnancy and employment for women after childbirth.

Both fluoxetine and cognitive-behavioural counselling given as a course of therapy are effective treatments for non-psychotic depression in postnatal women. After an initial session of counselling, additional benefit results from either fluoxetine or further counselling but there seems to be no advantage in receiving both. The choice of treatment may therefore be made by the women themselves.