In Reply

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In Reply:
We thank Drs. Taslimi and Dashtban for their interest in our commentary.1 They point out that depression screening at regular intervals extends beyond the current practice in obstetrics and gynecology. We agree that it is not common practice in obstetrics and gynecology to screen for depression as we described, and in fact hope that our commentary will underline the importance of making this common practice.
They also point out that integrated psychotherapy programs may not be accessible or affordable and recommend using bibliotherapy (self-help books) for mild-to-moderate depression. Bibliotherapy is commonly used as an adjunct to other treatments, and up to 97% of psychologists prescribe bibliotherapy.2 However, based on available evidence, we cannot recommend bibliotherapy as a first-line, stand-alone treatment for depression. Studies examining the efficacy of bibliotherapy are limited by small sample sizes and exclusion of patients with major depression.3 Moreover, to our knowledge, none of these studies were conducted in clinical populations, but recruited participants by advertising in the community. This raises concern for selection bias, especially for an intervention such as bibliotherapy that requires a degree of motivation. There are other considerations—the patient's reading age must be 12 years, and the books recommended must be culturally relevant and available in the patient's language. Additionally there are no guidelines regarding length of treatment or frequency of ongoing contact with the health care provider. Trials of bibliotherapy report weekly contact during treatment, similar to that in psychotherapy.4
In short, although recommending bibliotherapy may be better than doing nothing for a woman who screens positive for depression, the preponderance of research points to evidence-based psychotherapy (with or without antidepressants) as the treatment of choice for mild-to-moderate depression. These evidence-based treatments are cost-effective, decreasing the overall health care costs of a heavily burdened system,5 and acceptable to patients across cultures.6 It may seem challenging to provide proper evidence-based integrated treatment, but given the downstream effects of depression on women and their families, it is the right thing to do.
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