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Meta-Analysis
. 2021 Feb 13;2(2):CD013560.
doi: 10.1002/14651858.CD013560.pub2.

Antidepressant treatment for postnatal depression

Jennifer Valeska Elli Brown  1   2 , Claire A Wilson  3 , Karyn Ayre  3 , Lindsay Robertson  2   4 , Emily South  4 , Emma Molyneaux  3 , Kylee Trevillion  3 , Louise M Howard  3 , Hind Khalifeh  3
Affiliations
Meta-Analysis

Antidepressant treatment for postnatal depression

Jennifer Valeska Elli Brown et al. Cochrane Database Syst Rev. .

Abstract

Background: Depression is one of the most common morbidities of the postnatal period. It has been associated with adverse outcomes for women, children, the wider family and society as a whole. Treatment is with psychosocial interventions or antidepressant medication, or both. The aim of this review is to evaluate the effectiveness of different antidepressants and to compare their effectiveness with placebo, treatment as usual or other forms of treatment. This is an update of a review last published in 2014.

Objectives: To assess the effectiveness and safety of antidepressant drugs in comparison with any other treatment (psychological, psychosocial, or pharmacological), placebo, or treatment as usual for postnatal depression.

Search methods: We searched Cochrane Common Mental Disorders's Specialized Register, CENTRAL, MEDLINE, Embase and PsycINFO in May 2020. We also searched international trials registries and contacted experts in the field.

Selection criteria: We included randomised controlled trials (RCTs) of women with depression during the first 12 months postpartum that compared antidepressant treatment (alone or in combination with another treatment) with any other treatment, placebo or treatment as usual.

Data collection and analysis: Two review authors independently extracted data from the study reports. We requested missing information from study authors wherever possible. We sought data to allow an intention-to-treat analysis. Where we identified sufficient comparable studies we pooled data and conducted random-effects meta-analyses.

Main results: We identified 11 RCTs (1016 women), the majority of which were from English-speaking, high-income countries; two were from middle-income countries. Women were recruited from a mix of community-based, primary care, maternity and outpatient settings. Most studies used selective serotonin reuptake inhibitors (SSRIs), with treatment duration ranging from 4 to 12 weeks. Meta-analysis showed that there may be a benefit of SSRIs over placebo in response (55% versus 43%; pooled risk ratio (RR) 1.27, 95% confidence interval (CI) 0.97 to 1.66); remission (42% versus 27%; RR 1.54, 95% CI 0.99 to 2.41); and reduced depressive symptoms (standardised mean difference (SMD) -0.30, 95% CI -0.55 to -0.05; 4 studies, 251 women), at 5 to 12 weeks' follow-up. We were unable to conduct meta-analysis for adverse events due to variation in the reporting of this between studies. There was no evidence of a difference between acceptability of SSRI and placebo (27% versus 27%; RR 1.10, 95% CI 0.74 to 1.64; 4 studies; 233 women). The certainty of all the evidence for SSRIs was low or very low due to the small number of included studies and a number of potential sources of bias, including high rates of attrition. There was insufficient evidence to assess the efficacy of SSRIs compared with other classes of antidepressants and of antidepressants compared with other pharmacological interventions, complementary medicines, psychological and psychosocial interventions or treatment as usual. A substantial proportion of women experienced adverse effects but there was no evidence of differences in the number of adverse effects between treatment groups in any of the studies. Data on effects on children, including breastfed infants, parenting, and the wider family were limited, although no adverse effects were noted.

Authors' conclusions: There remains limited evidence regarding the effectiveness and safety of antidepressants in the management of postnatal depression, particularly for those with more severe depression. We found low-certainty evidence that SSRI antidepressants may be more effective in treating postnatal depression than placebo as measured by response and remission rates. However, the low certainty of the evidence suggests that further research is very likely to have an important impact on our effect estimate. There is a continued imperative to better understand whether, and for whom, antidepressants or other treatments are more effective for postnatal depression, and whether some antidepressants are more effective or better tolerated than others. In clinical practice, the findings of this review need to be contextualised by the extensive broader literature on antidepressants in the general population and perinatal clinical guidance, to inform an individualised risk-benefit clinical decision. Future RCTs should focus on larger samples, longer follow-up, comparisons with alternative treatment modalities and inclusion of child and parenting outcomes.

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Conflict of interest statement

JB: no conflicts of interest CW: no conflicts of interest KA: no conflicts of interest LR: no conflicts of interest ES: no conflicts of interest EM: no conflicts of interest KT: no conflicts of interest LH: has worked for the National Institute for Health and Care Excellence (NICE) Scientific Advice on pharmacological treatment for postnatal depression. HK: no conflicts of interest

Figures

1
1
Flow diagram illustrating the study selection process
2
2
Risk of bias graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies
3
3
Risk of bias summary: review authors' judgements about each 'Risk of bias' item for each included study
1.1
1.1. Analysis
Comparison 1: Antidepressants vs placebo, Outcome 1: Depression response (acute phase)
1.2
1.2. Analysis
Comparison 1: Antidepressants vs placebo, Outcome 2: Depression remission (acute phase)
1.3
1.3. Analysis
Comparison 1: Antidepressants vs placebo, Outcome 3: Severity of depression ‐ overall (acute phase)
1.4
1.4. Analysis
Comparison 1: Antidepressants vs placebo, Outcome 4: Severity of depression ‐ EPDS (acute phase)
1.5
1.5. Analysis
Comparison 1: Antidepressants vs placebo, Outcome 5: Severity of depression ‐ HAM‐D (acute phase)
1.6
1.6. Analysis
Comparison 1: Antidepressants vs placebo, Outcome 6: Severity of depression ‐ CGI‐S (acute phase)
1.7
1.7. Analysis
Comparison 1: Antidepressants vs placebo, Outcome 7: Treatment acceptability ‐ dropouts
2.1
2.1. Analysis
Comparison 2: Antidepressants vs treatment as usual, Outcome 1: Depression remission (early phase)
2.2
2.2. Analysis
Comparison 2: Antidepressants vs treatment as usual, Outcome 2: Severity of depression ‐ EPDS (early phase)
2.3
2.3. Analysis
Comparison 2: Antidepressants vs treatment as usual, Outcome 3: Treatment acceptability ‐ dropouts
2.4
2.4. Analysis
Comparison 2: Antidepressants vs treatment as usual, Outcome 4: Parenting‐related outcomes ‐ MAMA (early phase)
2.5
2.5. Analysis
Comparison 2: Antidepressants vs treatment as usual, Outcome 5: Parenting‐related outcomes ‐ MAMA (continuation phase)
2.6
2.6. Analysis
Comparison 2: Antidepressants vs treatment as usual, Outcome 6: Quality of life ‐ SF‐12 mental health
2.7
2.7. Analysis
Comparison 2: Antidepressants vs treatment as usual, Outcome 7: Quality of life ‐ SF‐12 physical health
2.8
2.8. Analysis
Comparison 2: Antidepressants vs treatment as usual, Outcome 8: Quality of life ‐ EQ5D utility score
2.9
2.9. Analysis
Comparison 2: Antidepressants vs treatment as usual, Outcome 9: Quality of life ‐ EQ5D visual analogue scale
3.1
3.1. Analysis
Comparison 3: Antidepressants vs psychological interventions, Outcome 1: Severity of depression ‐ EPDS (acute phase)
3.2
3.2. Analysis
Comparison 3: Antidepressants vs psychological interventions, Outcome 2: Severity of depression ‐ BDI (acute phase)
3.3
3.3. Analysis
Comparison 3: Antidepressants vs psychological interventions, Outcome 3: Severity of depression ‐ BDI (continuation phase)
3.4
3.4. Analysis
Comparison 3: Antidepressants vs psychological interventions, Outcome 4: Treatment acceptability
3.5
3.5. Analysis
Comparison 3: Antidepressants vs psychological interventions, Outcome 5: Parenting‐related outcomes ‐ PSI (acute phase)
3.6
3.6. Analysis
Comparison 3: Antidepressants vs psychological interventions, Outcome 6: Parenting‐related outcomes ‐ PSI (continuation phase)
4.1
4.1. Analysis
Comparison 4: Antidepressants vs psychosocial interventions, Outcome 1: Depression remission (continuation phase)
4.2
4.2. Analysis
Comparison 4: Antidepressants vs psychosocial interventions, Outcome 2: Severity of depression ‐ EPDS (continuation phase)
4.3
4.3. Analysis
Comparison 4: Antidepressants vs psychosocial interventions, Outcome 3: Treatment acceptability ‐ dropouts
4.4
4.4. Analysis
Comparison 4: Antidepressants vs psychosocial interventions, Outcome 4: Parenting‐related outcomes ‐ MAMA (continuation phase)
4.5
4.5. Analysis
Comparison 4: Antidepressants vs psychosocial interventions, Outcome 5: Quality of life ‐ SF12 mental health
4.6
4.6. Analysis
Comparison 4: Antidepressants vs psychosocial interventions, Outcome 6: Quality of life ‐ SF12 physical health
4.7
4.7. Analysis
Comparison 4: Antidepressants vs psychosocial interventions, Outcome 7: Quality of life ‐ EQ‐5D utility score
4.8
4.8. Analysis
Comparison 4: Antidepressants vs psychosocial interventions, Outcome 8: Quality of life ‐ EQ‐5D visual analogue scale
5.1
5.1. Analysis
Comparison 5: Antidepressant vs other pharmacological intervention, Outcome 1: Depression response ‐ acute phase
5.2
5.2. Analysis
Comparison 5: Antidepressant vs other pharmacological intervention, Outcome 2: Depression remission ‐ acute phase
5.3
5.3. Analysis
Comparison 5: Antidepressant vs other pharmacological intervention, Outcome 3: Depression response ‐ early phase
5.4
5.4. Analysis
Comparison 5: Antidepressant vs other pharmacological intervention, Outcome 4: Depression remission ‐ early phase
5.5
5.5. Analysis
Comparison 5: Antidepressant vs other pharmacological intervention, Outcome 5: Depression severity ‐ HAM‐D (acute phase)
5.6
5.6. Analysis
Comparison 5: Antidepressant vs other pharmacological intervention, Outcome 6: Treatment acceptability ‐ dropouts
6.1
6.1. Analysis
Comparison 6: Antidepressants vs complementary medicine, Outcome 1: Depression response ‐ acute phase
6.2
6.2. Analysis
Comparison 6: Antidepressants vs complementary medicine, Outcome 2: Depression remission ‐ acute phase
7.1
7.1. Analysis
Comparison 7: Sensitivity analysis ‐ antidepressant vs placebo, excluding studies at high risk of bias, Outcome 1: Depression response (acute phase)
7.2
7.2. Analysis
Comparison 7: Sensitivity analysis ‐ antidepressant vs placebo, excluding studies at high risk of bias, Outcome 2: Depression remission (acute phase)
7.3
7.3. Analysis
Comparison 7: Sensitivity analysis ‐ antidepressant vs placebo, excluding studies at high risk of bias, Outcome 3: Severity of depression ‐ overall (acute phase)
7.4
7.4. Analysis
Comparison 7: Sensitivity analysis ‐ antidepressant vs placebo, excluding studies at high risk of bias, Outcome 4: Severity of depression ‐ HAM‐D (acute phase)
7.5
7.5. Analysis
Comparison 7: Sensitivity analysis ‐ antidepressant vs placebo, excluding studies at high risk of bias, Outcome 5: Severity of depression ‐ CGI‐S (acute phase)
8.1
8.1. Analysis
Comparison 8: Sensitivity analysis ‐ antidepressant vs placebo, excluding studies with imputed data, Outcome 1: Severity of depression ‐ overall (acute phase)
8.2
8.2. Analysis
Comparison 8: Sensitivity analysis ‐ antidepressant vs placebo, excluding studies with imputed data, Outcome 2: Severity of depression ‐ HAM‐D (acute phase)
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Update of

  • doi: 10.1002/14651858.CD013560

References

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References to other published versions of this review

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