Research question 1: Does psychoeducation work and for whom?

A summary of quantitative results is presented in Table 2. Seven of the included studies reported on depression outcomes. One study^{Reference Kariuki, Kuria, Were and Ndetei44} reported on a standalone psychoeducation intervention for the primary prevention of PPD in new mothers (52.9% were aged under 25 years). The study found that psychoeducation significantly reduced depressive symptoms in the intervention group (P < 0.001) as compared with the control (usual care) group (P = 0.71), with between-group differences indicating moderate effects (d = 0.32). Six studies^{Reference Brugha, Wheatley, Taub, Culverwell, Friedman and Kirwan41–Reference Ginsburg, Barlow, Goklish, Hastings, Baker and Mullany43,Reference Phipps, Raker, Jocelyn and Zlotnick45–Reference Zlotnick, Miller, Pearlstein, Howard and Sweeny47} examined multicomponent interventions with psychoeducation for preventing PPD. Three^{Reference Brugha, Wheatley, Taub, Culverwell, Friedman and Kirwan41,Reference Kariuki, Kuria, Were and Ndetei44,Reference Phipps, Raker, Jocelyn and Zlotnick45} focused on universal/primary prevention (participants were not included based on diagnosis or elevated symptoms of depression) and three^{Reference Brugha, Wheatley, Taub, Culverwell, Friedman and Kirwan41,Reference Ginsburg, Barlow, Goklish, Hastings, Baker and Mullany43,Reference Zlotnick, Miller, Pearlstein, Howard and Sweeny47} focused on indicated prevention (participants recruited based on elevated symptoms of depression or risk of PPD). One study^{Reference Sangsawang, Deoisres, Hengudomsub and Sangsawang46} reported a significant effect of the intervention, compared with usual care on preventing PPD in first-time adolescent mothers with a mean age of 17.4 years, with large interventional effects (P < 0.05, d = 1.73). Zlotnick et al^{Reference Zlotnick, Miller, Pearlstein, Howard and Sweeny47} studied a sample of 99 pregnant women (mean age 22.4 years). It was found that the multicomponent intervention with psychoeducation reduced incidence of PPD at 3 months postpartum (4 and 20% of participants developed PPD at 3 months postpartum in the intervention and usual care (control) groups, respectively; P = 0.04). However, there was no effect of the intervention on severity of depressive symptoms. A study by Phipps et al^{Reference Phipps, Raker, Jocelyn and Zlotnick45} showed a lower incidence rate of PPD at 6 months postpartum for the intervention group (12.5%) when compared against the active control group (received a comprehensive pregnancy guide only), in a sample of 106 pregnant adolescents aged 13–18 years. However, the small sample size (n = 106) was underpowered to detect a statistically significant effect for the intervention. Ginsburg et al^{Reference Ginsburg, Barlow, Goklish, Hastings, Baker and Mullany43} found similar pre–post reductions in depression symptoms within intervention and control (education support – not focusing on mental health) groups delivered for a sample of pregnant young mothers aged 15–21 years (mean age 18.2 years). Study authors attributed this non-significant between-group difference to the study being underpowered (n = 47); non-specific therapeutic effects, since both groups received a weekly visit from an interventionist; and increased optimism, knowledge and self-efficacy as a result of providing information about pregnancy to participants in the control group.

Table 2 Summary of quantitative evidence

RCT, randomised controlled trial; STAI, State-Trait Anxiety Inventory; GHQ-D, General Health Questionnaire; EPDS, Edinburgh Postnatal Depression Scale; SCAN, Schedules for Clinical Assessment in Neuropsychiatry; CES-D, Centre for Epidemiologic Studies Depression Scale; BDI, Beck Depression Inventory; KID-SCID, Structured Clinical Interview for the DSM-IV Childhood Diagnoses.

a. No means were reported. However, P-values for between-group analyses were reported: there were no significant differences in state/trait anxiety (P =0.332, P = 0.052)

between the groups at baseline. At post-intervention, scores for state/trait anxiety showed significant decreases in the intervention group when compared with the control group (P < 0.001).

b. Odds of being a case of postnatal depression were reported only for participants who completed a sufficient number of sessions. Confidence intervals were reported but effect sizes were not reported. There was insufficient information to calculate effect sizes.

c. Exact P-values were not reported; however, it was reported that there were no significant differences between groups for each outcome measure. Effect sizes (Cohen's d) have been reported. The intervention showed potential in reducing depressive symptoms. Results were comparable at all follow-ups. The study also measured onset of major depressive disorder using the Diagnostic Interview Schedule for Children (DISC). There were no participants with a diagnosis of major depressive disorder at baseline, only two (8%) participants in the education support (control) group developed major depressive disorder across all assessment points.

d. No baseline characteristics were reported. Incidence of major depression (i.e. number of cases for each group) at follow-up 1 and complete follow-up (in the postnatal period) was reported. The results were comparable at both follow-ups. Confidence intervals were reported but effect sizes were not reported. There was insufficient information to calculate effect sizes.

e. P-values were not reported. However, incidence was reported: two (4%) participants in the intervention group and eight (20%) participants in the control group developed/were diagnosed with depression at 3 months postpartum (P = 0.04).

Null effects were also reported by Brugha et al^{Reference Brugha, Wheatley, Taub, Culverwell, Friedman and Kirwan41} when comparing intervention with the usual care (control) group in a sample of 209 pregnant women (mean age 19.0 years). Similarly, a study by Dugravier et al^{Reference Dugravier, Tubach, Guedeney, Pasquet, Purper-Ouakil and Tereno42} did not find an effect of the multicomponent intervention with psychoeducation on PPD (P = 0.28) when delivered for a sample of 327 pregnant women (mean age 22.3 years). However, post hoc analysis in this study revealed that in certain subgroups, the intervention resulted in significantly lower scores: participants with fewer depressive symptoms at recruitment (P = 0.05), women with a partner involved in raising the child (P = 0.04) and women with a higher level of education (P = 0.05).

One study^{Reference Bastani, Hidarnia, Montgomery, Aguila-Vafaaei and Kazemnejad40} (treatment) reported on anxiety as a secondary outcome (birth outcomes were the primary study outcome) in an evaluation of relaxation therapy (which included a discussion on anxiety in pregnancy) compared with usual care in a sample of 110 pregnant women (mean age 23.8 years). This intervention significantly decreased scores for state/trait anxiety in the intervention group as compared with the control group (P < 0.001), but the effect size was not reported.

None of the studies carried out moderation analyses to examine the effect of age or clinical severity. Comparing across studies revealed no obvious trends. Also, the qualitative studies included in this review did not address the question related to potential moderators of effectiveness or acceptability of psychoeducation interventions, such as clinical severity, or age of young mothers.

In discussing with the YAG, the panel indicated that a key strength of psychoeducation was the focus on increasing awareness of mental health problems and preparedness to face stressors that can negatively affect mental health during pregnancy and following childbirth (Table 3). It was felt that improved mental health literacy owing to psychoeducation would be equally relevant to depression and anxiety. It was also noted that psychoeducation has potential benefits when delivered both prenatally and postnatally.

Table 3 Meta-synthesis of qualitative evidence and youth advisory group lived experience

On the other hand, the YAG felt that psychoeducation was in itself not sufficient to address all the needs of young parents during both the prenatal and postpartum periods. This echoed the view that no single ‘ingredient’ would be able to fully address perinatal mental disorders. Therefore, psychoeducation was considered less potent as standalone programme than a multicomponent programme. Specifically, the YAG said they would benefit from lessons on transitioning to motherhood in addition to psychoeducation.

In terms of age appropriateness for perinatal psychoeducation, there was consensus that adolescents aged under 18 years would derive greatest benefit, as they may be more at risk of depression and anxiety during the perinatal period because of the stigma associated with early pregnancies. This aspect was specifically highlighted by youth advisors from Malawi, where many young women give birth before 18 years of age.

Research question 2: In which contexts and settings does psychoeducation work?

Five studies were conducted in high-income countries and three were completed in LMICs (Kenya, Thailand and Iran). The LMIC studies indicated that psychoeducation was effective in preventing PPD (P < 0.001, d = 0.32^{Reference Kariuki, Kuria, Were and Ndetei44}; P < 0.05, d = 1.73)^{Reference Sangsawang, Deoisres, Hengudomsub and Sangsawang46} and reducing symptoms of anxiety (P < 0.001).^{Reference Bastani, Hidarnia, Montgomery, Aguila-Vafaaei and Kazemnejad40} Only one study from high-income countries provided evidence for the effectiveness of psychoeducation (P = 0.04).^{Reference Zlotnick, Miller, Pearlstein, Howard and Sweeny47} In terms of duration, three psychoeducation interventions were brief (one to six sessions), with two being effective (P < 0.001, d = 0.32;^{Reference Kariuki, Kuria, Were and Ndetei44} P = 0.04)^{Reference Zlotnick, Miller, Pearlstein, Howard and Sweeny47} and one being ineffective.^{Reference Phipps, Raker, Jocelyn and Zlotnick45} Longer interventions^{Reference Brugha, Wheatley, Taub, Culverwell, Friedman and Kirwan41–Reference Ginsburg, Barlow, Goklish, Hastings, Baker and Mullany43,Reference Sangsawang, Deoisres, Hengudomsub and Sangsawang46} also yielded mixed results, with two being effective (P < 0.001;^{Reference Bastani, Hidarnia, Montgomery, Aguila-Vafaaei and Kazemnejad40} P < 0.05, d = 1.73)^{Reference Sangsawang, Deoisres, Hengudomsub and Sangsawang46} and three being ineffective.^{Reference Brugha, Wheatley, Taub, Culverwell, Friedman and Kirwan41–Reference Ginsburg, Barlow, Goklish, Hastings, Baker and Mullany43}

For interventions delivered face to face, effectiveness was reported for two interventions (P < 0.001, d = 0.32;^{Reference Kariuki, Kuria, Were and Ndetei44} P < 0.05, d = 1.73),^{Reference Sangsawang, Deoisres, Hengudomsub and Sangsawang46} whereas two studies were reported to be ineffective.^{Reference Dugravier, Tubach, Guedeney, Pasquet, Purper-Ouakil and Tereno42,Reference Ginsburg, Barlow, Goklish, Hastings, Baker and Mullany43} Two group interventions were found to be effective (P < 0.001;^{Reference Bastani, Hidarnia, Montgomery, Aguila-Vafaaei and Kazemnejad40} P = 0.04),^{Reference Zlotnick, Miller, Pearlstein, Howard and Sweeny47} whereas one was ineffective.^{Reference Brugha, Wheatley, Taub, Culverwell, Friedman and Kirwan41} One study delivered through a combination of one-to-one and group delivery was found to be ineffective.^{Reference Phipps, Raker, Jocelyn and Zlotnick45} Out of the five interventions delivered by nurses, four were effective (P < 0.001;^{Reference Bastani, Hidarnia, Montgomery, Aguila-Vafaaei and Kazemnejad40} P < 0.001, d = 0.32;^{Reference Kariuki, Kuria, Were and Ndetei44} P < 0.05, d = 1.73;^{Reference Sangsawang, Deoisres, Hengudomsub and Sangsawang46} P = 0.04)^{Reference Zlotnick, Miller, Pearlstein, Howard and Sweeny47} and one was ineffective.^{Reference Brugha, Wheatley, Taub, Culverwell, Friedman and Kirwan41} No effectiveness of the intervention was found for studies delivered by psychologists^{Reference Dugravier, Tubach, Guedeney, Pasquet, Purper-Ouakil and Tereno42} and lay counsellors.^{Reference Ginsburg, Barlow, Goklish, Hastings, Baker and Mullany43} One study that was ineffective^{Reference Phipps, Raker, Jocelyn and Zlotnick45} did not state what kind of facilitators were used. In terms of study setting, effectiveness was reported for a study that used a combination of clinic and home sessions (P < 0.05, d = 1.73),^{Reference Sangsawang, Deoisres, Hengudomsub and Sangsawang46} whereas interventions that utilised home delivery were ineffective.^{Reference Dugravier, Tubach, Guedeney, Pasquet, Purper-Ouakil and Tereno42,Reference Ginsburg, Barlow, Goklish, Hastings, Baker and Mullany43} Mixed results were reported for studies delivered in health and/or child clinics, with three studies being effective (P < 0.001;^{Reference Bastani, Hidarnia, Montgomery, Aguila-Vafaaei and Kazemnejad40} P < 0.001, d = 0.32;^{Reference Kariuki, Kuria, Were and Ndetei44} P = 0.04)^{Reference Zlotnick, Miller, Pearlstein, Howard and Sweeny47} and two being ineffective.^{Reference Brugha, Wheatley, Taub, Culverwell, Friedman and Kirwan41,Reference Phipps, Raker, Jocelyn and Zlotnick45}

Qualitative evidence revealed that psychoeducation was deemed to be more engaging by the participants when delivered in brief and visually appealing formats, such as leaflets with bullet points; when incorporating stories about real people's experiences^{Reference Boath, Henshaw and Bradley50} and when facilitated by another person in a kind, non-judgemental and supportive way.^{Reference Recto and Champion59}

The role of midwives as providers of psychoeducation was highlighted by adolescent mothers as potentially problematic, as participants recalled experiences of being judged by maternal healthcare providers in LMICs.^{Reference Kola, Benerr, Bhat, Ayinde, Oladeji and Abiona54} This view was not universal, as other participants reported having positive experiences with midwives and other maternal care professionals.^{Reference Kola, Benerr, Bhat, Ayinde, Oladeji and Abiona54} Participants positively commented on peers delivering the psychoeducation programme saying, ‘ … they understand more what you feel may be your problems’.^{Reference Boath, Henshaw and Bradley50} The positive aspects of having access to social support groups was also acknowledged by participants in the qualitative studies.^{Reference Kinser and Masho53,Reference Nakku, Okello, Kizza, Honikman, Ssebunnya and Ndyanabangi57} Therefore, having group discussions within the psychoeducation intervention could have additional benefits.

Finally, television and social media platforms were seen as having a potentially useful role in accessing psychoeducation, as they are easily accessible by young mothers from their homes.^{Reference Cadigan and Skinner51} On the other hand, participants noted that information on social media can be problematic because it may not always be accurate.^{Reference Recto and Champion59}

The YAG agreed that psychoeducation can be adapted across diverse contexts. Psychologists were the most preferred provider of psychoeducation as they were perceived to be more knowledgeable about mental health issues, followed by community health workers and midwives. A number of advisors also expressed a preference for accessing psychoeducation from healthcare workers in antenatal/postnatal clinics. However, other advisors argued that interventions delivered at home would be more convenient and comfortable for young mothers. There was consensus that peers, including support groups on social media, can be an important source of psychoeducation. However, young advisors believed that trustworthy information was more likely to be delivered by health professionals, who are professionally trained and more experienced in mental health, rather than peers.

Research question 3: Why does psychoeducation work?

None of the included studies specifically conducted mediation analyses to test for plausible mechanisms. Experiential accounts of psychoeducation highlighted possible mechanisms for psychoeducation in four linked domains (Table 3). First, several studies demonstrated a widespread lack of knowledge about symptoms of perinatal depression and anxiety, and psychoeducation was helpful at improving self-recognition of these conditions.^{Reference Baldisserotto, Theme, Gomez and dos Reis49,Reference Boath, Henshaw and Bradley50,Reference Guy, Sterling, Walker and Harrison52,Reference Nakku, Okello, Kizza, Honikman, Ssebunnya and Ndyanabangi57}

Second, psychoeducational approaches helped young mothers to learn self-management strategies for coping with stressful situations and symptoms of depression, both during pregnancy and postpartum.

Third, information about relevant professional mental health services was also valued.^{Reference Cadigan and Skinner51} Fourth, qualitative studies showed how fears of stigma (‘She probably would be judged … Maybe like they'll think she's weak, and I guess, immature’),^{Reference Recto and Champion58} mostly resulting from lack of professional information about the illness, can discourage young parents from opening up about their mental health difficulties. Such stigma may discourage appropriate help-seeking from healthcare providers, delaying diagnosis and treatment.^{Reference Boath, Henshaw and Bradley50,Reference Kola, Benerr, Bhat, Ayinde, Oladeji and Abiona54} Psychoeducation was considered effective at addressing the knowledge deficits that underpin mental health stigma, thereby encouraging formal help-seeking at an earlier stage.^{Reference Baldisserotto, Theme, Gomez and dos Reis49} Relational aspects of psychoeducation were also discussed. There were indications that the positive experience of the therapeutic alliance with providers of psychoeducation led to increased motivation and hopefulness about managing future challenges.^{Reference Kola, Benerr, Bhat, Ayinde, Oladeji and Abiona54,Reference Logsdon, Foltz, Stein, Usui and Josephson56}

The youth advisors reiterated the beneficial effects of psychoeducation on coping. They stated that psychoeducation can improve self-efficacy, leading to positive expectations about the ability to deal with mental health problems in the present and future. In this way, psychoeducation was seen as a way to empower young parents and motivate further positive actions, such as seeking professional help and advice. There was also a unanimous view that the working relationship (therapeutic alliance) between the therapist and the client was a key factor as it validates one's feelings, thereby increasing the patient's adherence to the prevention or treatment plan.