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JMIR MHealth and UHealth Oct 2021Postpartum depression (PPD) is a prevalent mental health problem with serious adverse consequences for affected women and their infants. Clinical trials have found that... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Postpartum depression (PPD) is a prevalent mental health problem with serious adverse consequences for affected women and their infants. Clinical trials have found that telehealth interventions for women with PPD result in increased accessibility and improved treatment effectiveness. However, no comprehensive synthesis of evidence from clinical trials by systematic review has been conducted.
OBJECTIVE
The aim of this study is to evaluate the effectiveness of telehealth interventions in reducing depressive symptoms and anxiety in women with PPD. To enhance the homogeneity and interpretability of the findings, this systematic review focuses on PPD measured by the Edinburgh Postnatal Depression Scale (EPDS).
METHODS
PubMed, The Cochrane Library, CINAHL, PsycINFO, CNKI, and Wanfang were electronically searched to identify randomized controlled trials (RCTs) on the effectiveness of telehealth interventions for women with PPD from inception to February 28, 2021. Data extraction and quality assessment were performed independently by two researchers. The quality of included studies was assessed using the Cochrane risk-of-bias tool, and meta-analysis was performed using RevMan 5.4 software.
RESULTS
Following the search, 9 RCTs with a total of 1958 women with PPD were included. The EPDS (mean difference=-2.99, 95% CI -4.52 to -1.46; P<.001) and anxiety (standardized mean difference=-0.39, 95% CI -0.67 to -0.12; P=.005) scores were significantly lower in the telehealth group compared with the control group. Significant subgroup differences were found in depressive symptoms according to the severity of PPD, telehealth technology, specific therapy, and follow-up time (P<.001).
CONCLUSIONS
Telehealth interventions could effectively reduce the symptoms of depression and anxiety in women with PPD. However, better designed and more rigorous large-scale RCTs targeting specific therapies are needed to further explore the potential of telehealth interventions for PPD.
TRIAL REGISTRATION
PROSPERO CRD42021258541; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=258541.
Topics: Anxiety; Depression, Postpartum; Female; Humans; Infant; Telemedicine; Treatment Outcome
PubMed: 34617909
DOI: 10.2196/32544 -
International Journal of Environmental... Apr 2020Pregnancy is a period of complex bio-psychological changes, during which the development of an attachment bond to the fetus takes on a central role. Depressive symptoms... (Meta-Analysis)
Meta-Analysis
Pregnancy is a period of complex bio-psychological changes, during which the development of an attachment bond to the fetus takes on a central role. Depressive symptoms are common during this period. Both symptoms of depression and low levels of prenatal attachment are related to negative outcomes in caregivers and infants. Following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement, this systematic review analyzes and systematizes 41 studies concerning the association between prenatal attachment and perinatal depression. The majority of the studies reported a significant association between the two. Specifically, prenatal depressive symptoms were found to be negatively associated with prenatal attachment. Furthermore, lower levels of prenatal attachment were related to higher postnatal depressive symptoms, although fewer studies assessed this association. While these results were found across different populations, conflicting findings emerged, suggesting they should be interpreted with caution, particularly in male samples and in non-normative pregnancies (e.g., high-risk pregnancies, medically assisted pregnancies, and pregnancies with previous perinatal losses). These results are clinically important for the perinatal screening process and for implementing preventive and treatment programs. However, future studies are needed to further confirm and generalize these results.
Topics: Depression; Depression, Postpartum; Depressive Disorder; Female; Fetus; Humans; Infant; Male; Mother-Child Relations; Mothers; Pregnancy
PubMed: 32290590
DOI: 10.3390/ijerph17082644 -
JAMA Nov 2022Unintended pregnancy is common in the US and is associated with adverse maternal and infant health outcomes; however, estimates of these associations specific to current... (Comparative Study)
Comparative Study Meta-Analysis
IMPORTANCE
Unintended pregnancy is common in the US and is associated with adverse maternal and infant health outcomes; however, estimates of these associations specific to current US populations are lacking.
OBJECTIVE
To evaluate associations of unintended pregnancy with maternal and infant health outcomes during pregnancy and post partum with studies relevant to current clinical practice and public health in the US.
DATA SOURCES
Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PsycINFO, SocINDEX, and MEDLINE databases (January 1, 2000, to June 15, 2022) and manual review of reference lists.
STUDY SELECTION
Epidemiologic studies relevant to US populations that compared key maternal and infant health outcomes for unintended vs intended pregnancies and met prespecified eligibility criteria were included after investigators' independent dual review of abstracts and full-text articles.
DATA EXTRACTION AND SYNTHESIS
Investigators abstracted data from publications on study methods, participant characteristics, settings, pregnancy intention, comparators, confounders, and outcomes; data were validated by a second investigator. Risk of bias was independently dual rated by investigators using criteria developed by the US Preventive Services Task Force. Results of studies controlling for confounders were combined by using a profile likelihood random-effects model.
MAIN OUTCOMES AND MEASURES
Prenatal depression, postpartum depression, maternal experience of interpersonal violence, preterm birth, and infant low birth weight.
RESULTS
Thirty-six studies (N = 524 522 participants) were included (14 cohort studies rated good or fair quality; 22 cross-sectional studies); 12 studies used large population-based data sources. Compared with intended pregnancy, unintended pregnancy was significantly associated with higher odds of depression during pregnancy (23.3% vs 13.9%; adjusted odds ratio [aOR], 1.59 [95% CI, 1.35-1.92]; I2 = 85.0%; 15 studies [n = 41 054]) and post partum (15.7% vs 9.6%; aOR, 1.51 [95% CI, 1.40-1.70]; I2 = 7.1%; 10 studies [n = 82 673]), interpersonal violence (14.6% vs 5.5%; aOR, 2.22 [95% CI, 1.41-2.91]; I2 = 64.1%; 5 studies [n = 42 306]), preterm birth (9.4% vs 7.7%; aOR, 1.21 [95% CI, 1.12-1.31]; I2 = 1.7%; 10 studies [n = 94 351]), and infant low birth weight (7.3% vs 5.2%; aOR, 1.09 [95% CI, 1.02-1.21]; I2 = 0.0%; 8 studies [n = 87 547]). Results were similar in sensitivity analyses based on controlling for history of depression for prenatal and postpartum depression and on study design and definition of unintended pregnancy for relevant outcomes. Studies provided limited sociodemographic data and measurement of confounders and outcomes varied.
CONCLUSIONS AND RELEVANCE
In this systematic review and meta-analysis of epidemiologic observational studies relevant to US populations, unintended pregnancy, compared with intended pregnancy, was significantly associated with adverse maternal and infant outcomes.
TRIAL REGISTRATION
PROSPERO Identifier: CRD42020192981.
Topics: Female; Humans; Infant; Infant, Newborn; Pregnancy; Birth Weight; Cross-Sectional Studies; Depression, Postpartum; Infant Health; Infant, Low Birth Weight; Observational Studies as Topic; Pregnancy, Unplanned; Premature Birth; Pregnancy Outcome; Maternal Health; United States; Violence; Pregnancy Complications
PubMed: 36318133
DOI: 10.1001/jama.2022.19097 -
Medicina (Kaunas, Lithuania) Sep 2019During pregnancy and the postnatal period many changes occur in a woman's body, both in mental and physical spheres. The birth of a child and a new role-of a...
During pregnancy and the postnatal period many changes occur in a woman's body, both in mental and physical spheres. The birth of a child and a new role-of a mother-can sometimes be associated with numerous negative emotions, uncertainty, fear, anxiety, disgust, depression, or sadness. In the puerperium period, the development of baby blues or postpartum depression may occur. Postpartum depression develops within one month of childbirth and may last up to one year. Depressive disorders that may develop in a young mother affect both her and the newborn's health. That is why it is so important to try to search for factors that could significantly reduce the likelihood of developing depression in this period. The study aims at assessing the relationship between physical activity during pregnancy and puerperium or in the postpartum and the development of postnatal depression. A review of the literature was carried out in the Medline-PubMed database. The search terms were "pregnancy" AND "physical activity AND postpartum depression". The study included only English-language publications published in the period 2000-2018. A total of 216 references were found. After establishing the inclusion and exclusion criteria based on the analysis of titles and abstracts, 173 articles were excluded from the review. A total of 43 publications were read in full. Finally, 16 articles were included in the review. It was shown that regular physical activity during pregnancy, pregnancy, and puerperium, or in the postnatal period itself as compared to inactivity, reduces the risk of developing depression in pregnant women and after the birth of a child. Physical activity can be an essential factor in the prevention of depressive disorders of women in the postnatal period.
Topics: Depression, Postpartum; Exercise; Female; Humans; Postpartum Period; Pregnancy
PubMed: 31480778
DOI: 10.3390/medicina55090560 -
BMJ (Clinical Research Ed.) Nov 2020To evaluate the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression in pregnant and postpartum women. (Meta-Analysis)
Meta-Analysis
Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data.
OBJECTIVE
To evaluate the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression in pregnant and postpartum women.
DESIGN
Individual participant data meta-analysis.
DATA SOURCES
Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, and Web of Science (from inception to 3 October 2018).
ELIGIBILITY CRITERIA FOR SELECTING STUDIES
Eligible datasets included EPDS scores and major depression classification based on validated diagnostic interviews. Bivariate random effects meta-analysis was used to estimate EPDS sensitivity and specificity compared with semi-structured, fully structured (Mini International Neuropsychiatric Interview (MINI) excluded), and MINI diagnostic interviews separately using individual participant data. One stage meta-regression was used to examine accuracy by reference standard categories and participant characteristics.
RESULTS
Individual participant data were obtained from 58 of 83 eligible studies (70%; 15 557 of 22 788 eligible participants (68%), 2069 with major depression). Combined sensitivity and specificity was maximised at a cut-off value of 11 or higher across reference standards. Among studies with a semi-structured interview (36 studies, 9066 participants, 1330 with major depression), sensitivity and specificity were 0.85 (95% confidence interval 0.79 to 0.90) and 0.84 (0.79 to 0.88) for a cut-off value of 10 or higher, 0.81 (0.75 to 0.87) and 0.88 (0.85 to 0.91) for a cut-off value of 11 or higher, and 0.66 (0.58 to 0.74) and 0.95 (0.92 to 0.96) for a cut-off value of 13 or higher, respectively. Accuracy was similar across reference standards and subgroups, including for pregnant and postpartum women.
CONCLUSIONS
An EPDS cut-off value of 11 or higher maximised combined sensitivity and specificity; a cut-off value of 13 or higher was less sensitive but more specific. To identify pregnant and postpartum women with higher symptom levels, a cut-off of 13 or higher could be used. Lower cut-off values could be used if the intention is to avoid false negatives and identify most patients who meet diagnostic criteria.
REGISTRATION
PROSPERO (CRD42015024785).
Topics: Depression, Postpartum; Depressive Disorder, Major; Female; Humans; Pregnancy; Pregnancy Complications; Prenatal Care; Psychometrics; Sensitivity and Specificity
PubMed: 33177069
DOI: 10.1136/bmj.m4022 -
The Lancet. Global Health Jun 2021The COVID-19 pandemic has had a profound impact on health-care systems and potentially on pregnancy outcomes, but no systematic synthesis of evidence of this effect has... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The COVID-19 pandemic has had a profound impact on health-care systems and potentially on pregnancy outcomes, but no systematic synthesis of evidence of this effect has been undertaken. We aimed to assess the collective evidence on the effects on maternal, fetal, and neonatal outcomes of the pandemic.
METHODS
We did a systematic review and meta-analysis of studies on the effects of the pandemic on maternal, fetal, and neonatal outcomes. We searched MEDLINE and Embase in accordance with PRISMA guidelines, from Jan 1, 2020, to Jan 8, 2021, for case-control studies, cohort studies, and brief reports comparing maternal and perinatal mortality, maternal morbidity, pregnancy complications, and intrapartum and neonatal outcomes before and during the pandemic. We also planned to record any additional maternal and offspring outcomes identified. Studies of solely SARS-CoV-2-infected pregnant individuals, as well as case reports, studies without comparison groups, narrative or systematic literature reviews, preprints, and studies reporting on overlapping populations were excluded. Quantitative meta-analysis was done for an outcome when more than one study presented relevant data. Random-effects estimate of the pooled odds ratio (OR) of each outcome were generated with use of the Mantel-Haenszel method. This review was registered with PROSPERO (CRD42020211753).
FINDINGS
The search identified 3592 citations, of which 40 studies were included. We identified significant increases in stillbirth (pooled OR 1·28 [95% CI 1·07-1·54]; I=63%; 12 studies, 168 295 pregnancies during and 198 993 before the pandemic) and maternal death (1·37 [1·22-1·53; I=0%, two studies [both from low-income and middle-income countries], 1 237 018 and 2 224 859 pregnancies) during versus before the pandemic. Preterm births before 37 weeks' gestation were not significantly changed overall (0·94 [0·87-1·02]; I=75%; 15 studies, 170 640 and 656 423 pregnancies) but were decreased in high-income countries (0·91 [0·84-0·99]; I=63%; 12 studies, 159 987 and 635 118 pregnancies), where spontaneous preterm birth was also decreased (0·81 [0·67-0·97]; two studies, 4204 and 6818 pregnancies). Mean Edinburgh Postnatal Depression Scale scores were higher, indicating poorer mental health, during versus before the pandemic (pooled mean difference 0·42 [95% CI 0·02-0·81; three studies, 2330 and 6517 pregnancies). Surgically managed ectopic pregnancies were increased during the pandemic (OR 5·81 [2·16-15·6]; I=26%; three studies, 37 and 272 pregnancies). No overall significant effects were identified for other outcomes included in the quantitative analysis: maternal gestational diabetes; hypertensive disorders of pregnancy; preterm birth before 34 weeks', 32 weeks', or 28 weeks' gestation; iatrogenic preterm birth; labour induction; modes of delivery (spontaneous vaginal delivery, caesarean section, or instrumental delivery); post-partum haemorrhage; neonatal death; low birthweight (<2500 g); neonatal intensive care unit admission; or Apgar score less than 7 at 5 min.
INTERPRETATION
Global maternal and fetal outcomes have worsened during the COVID-19 pandemic, with an increase in maternal deaths, stillbirth, ruptured ectopic pregnancies, and maternal depression. Some outcomes show considerable disparity between high-resource and low-resource settings. There is an urgent need to prioritise safe, accessible, and equitable maternity care within the strategic response to this pandemic and in future health crises.
FUNDING
None.
Topics: COVID-19; Female; Global Health; Humans; Infant, Newborn; Pregnancy; Pregnancy Outcome
PubMed: 33811827
DOI: 10.1016/S2214-109X(21)00079-6 -
The Cochrane Database of Systematic... Jul 2017Historically, women have generally been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has often...
BACKGROUND
Historically, women have generally been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has often become the exception rather than the routine.
OBJECTIVES
The primary objective was to assess the effects, on women and their babies, of continuous, one-to-one intrapartum support compared with usual care, in any setting. Secondary objectives were to determine whether the effects of continuous support are influenced by:1. Routine practices and policies in the birth environment that may affect a woman's autonomy, freedom of movement and ability to cope with labour, including: policies about the presence of support people of the woman's own choosing; epidural analgesia; and continuous electronic fetal monitoring.2. The provider's relationship to the woman and to the facility: staff member of the facility (and thus has additional loyalties or responsibilities); not a staff member and not part of the woman's social network (present solely for the purpose of providing continuous support, e.g. a doula); or a person chosen by the woman from family members and friends;3. Timing of onset (early or later in labour);4. Model of support (support provided only around the time of childbirth or extended to include support during the antenatal and postpartum periods);5. Country income level (high-income compared to low- and middle-income).
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (1 June 2017) and reference lists of retrieved studies.
SELECTION CRITERIA
All published and unpublished randomised controlled trials, cluster-randomised trials comparing continuous support during labour with usual care. Quasi-randomised and cross-over designs were not eligible for inclusion.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We sought additional information from the trial authors. The quality of the evidence was assessed using the GRADE approach.
MAIN RESULTS
We included a total of 27 trials, and 26 trials involving 15,858 women provided usable outcome data for analysis. These trials were conducted in 17 different countries: 13 trials were conducted in high-income settings; 13 trials in middle-income settings; and no studies in low-income settings. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (average RR 1.08, 95% confidence interval (CI) 1.04 to 1.12; 21 trials, 14,369 women; low-quality evidence) and less likely to report negative ratings of or feelings about their childbirth experience (average RR 0.69, 95% CI 0.59 to 0.79; 11 trials, 11,133 women; low-quality evidence) and to use any intrapartum analgesia (average RR 0.90, 95% CI 0.84 to 0.96; 15 trials, 12,433 women). In addition, their labours were shorter (MD -0.69 hours, 95% CI -1.04 to -0.34; 13 trials, 5429 women; low-quality evidence), they were less likely to have a caesarean birth (average RR 0.75, 95% CI 0.64 to 0.88; 24 trials, 15,347 women; low-quality evidence) or instrumental vaginal birth (RR 0.90, 95% CI 0.85 to 0.96; 19 trials, 14,118 women), regional analgesia (average RR 0.93, 95% CI 0.88 to 0.99; 9 trials, 11,444 women), or a baby with a low five-minute Apgar score (RR 0.62, 95% CI 0.46 to 0.85; 14 trials, 12,615 women). Data from two trials for postpartum depression were not combined due to differences in women, hospitals and care providers included; both trials found fewer women developed depressive symptomatology if they had been supported in birth, although this may have been a chance result in one of the studies (low-quality evidence). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, such as admission to special care nursery (average RR 0.97, 95% CI 0.76 to 1.25; 7 trials, 8897 women; low-quality evidence), and exclusive or any breastfeeding at any time point (average RR 1.05, 95% CI 0.96 to 1.16; 4 trials, 5584 women; low-quality evidence).Subgroup analyses suggested that continuous support was most effective at reducing caesarean birth, when the provider was present in a doula role, and in settings in which epidural analgesia was not routinely available. Continuous labour support in settings where women were not permitted to have companions of their choosing with them in labour, was associated with greater likelihood of spontaneous vaginal birth and lower likelihood of a caesarean birth. Subgroup analysis of trials conducted in high-income compared with trials in middle-income countries suggests that continuous labour support offers similar benefits to women and babies for most outcomes, with the exception of caesarean birth, where studies from middle-income countries showed a larger reduction in caesarean birth. No conclusions could be drawn about low-income settings, electronic fetal monitoring, the timing of onset of continuous support or model of support.Risk of bias varied in included studies: no study clearly blinded women and personnel; only one study sufficiently blinded outcome assessors. All other domains were of varying degrees of risk of bias. The quality of evidence was downgraded for lack of blinding in studies and other limitations in study designs, inconsistency, or imprecision of effect estimates.
AUTHORS' CONCLUSIONS
Continuous support during labour may improve outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration of labour, and decreased caesarean birth, instrumental vaginal birth, use of any analgesia, use of regional analgesia, low five-minute Apgar score and negative feelings about childbirth experiences. We found no evidence of harms of continuous labour support. Subgroup analyses should be interpreted with caution, and considered as exploratory and hypothesis-generating, but evidence suggests continuous support with certain provider characteristics, in settings where epidural analgesia was not routinely available, in settings where women were not permitted to have companions of their choosing in labour, and in middle-income country settings, may have a favourable impact on outcomes such as caesarean birth. Future research on continuous support during labour could focus on longer-term outcomes (breastfeeding, mother-infant interactions, postpartum depression, self-esteem, difficulty mothering) and include more woman-centred outcomes in low-income settings.
Topics: Cesarean Section; Delivery, Obstetric; Doulas; Female; Humans; Labor, Obstetric; Personal Autonomy; Pregnancy; Pregnancy Outcome; Professional-Patient Relations
PubMed: 28681500
DOI: 10.1002/14651858.CD003766.pub6 -
Clinical Psychology Review Dec 2018Women with psychiatric disorders during pregnancy and the postpartum period (i.e., perinatal period) are at increased risk for adverse maternal and child outcomes....
Women with psychiatric disorders during pregnancy and the postpartum period (i.e., perinatal period) are at increased risk for adverse maternal and child outcomes. Effective treatment of psychiatric disorders during the perinatal period is imperative. This review summarizes the outcomes of 78 studies focused on the treatment of depression, anxiety, and trauma-related disorders during the perinatal period. The majority of studies focused on perinatal depression (n = 73). Of the five studies focused on anxiety or trauma-related disorders, only one was a randomized controlled trial (RCT). The most studied treatment was cognitive behavioral therapy (CBT; n = 22), followed by interpersonal psychotherapy (IPT; n = 13). Other interventions reviewed include other talk therapies (n = 5), collaborative care models (n = 2), complementary and alternative medicine approaches (n = 18), light therapy (n = 3), brain stimulation (n = 2), and psychopharmacological interventions (n = 13). Eleven studies focused specifically on treatment for low-income and/or minority women. Both CBT and IPT demonstrated a significant benefit over control conditions. However, findings were mixed when these interventions were examined in low-income and/or minority samples. There is some support for complementary and alternative medicine approaches (e.g., exercise). Although scarce, SSRIs demonstrated good efficacy when compared to a placebo. However, SSRIs did not outperform another active treatment condition (e.g., CBT). There is a tremendous need for more studies focused on treatment of perinatal anxiety and trauma-related disorders, as well as psychopharmacological effectiveness studies. Limitations and future directions of perinatal treatment research, particularly among low-income and/or minority populations, are discussed.
Topics: Anxiety Disorders; Complementary Therapies; Depressive Disorder; Female; Humans; Pregnancy; Pregnancy Complications; Psychotherapy; Trauma and Stressor Related Disorders
PubMed: 29935979
DOI: 10.1016/j.cpr.2018.06.004 -
PloS One 2022Public health and epidemiologic research have established that social connectedness promotes overall health. Yet there have been no recent reviews of findings from... (Review)
Review
Public health and epidemiologic research have established that social connectedness promotes overall health. Yet there have been no recent reviews of findings from research examining social connectedness as a determinant of mental health. The goal of this review was to evaluate recent longitudinal research probing the effects of social connectedness on depression and anxiety symptoms and diagnoses in the general population. A scoping review was performed of PubMed and PsychInfo databases from January 2015 to December 2021 following PRISMA-ScR guidelines using a defined search strategy. The search yielded 66 unique studies. In research with other than pregnant women, 83% (19 of 23) studies reported that social support benefited symptoms of depression with the remaining 17% (5 of 23) reporting minimal or no evidence that lower levels of social support predict depression at follow-up. In research with pregnant women, 83% (24 of 29 studies) found that low social support increased postpartum depressive symptoms. Among 8 of 9 studies that focused on loneliness, feeling lonely at baseline was related to adverse outcomes at follow-up including higher risks of major depressive disorder, depressive symptom severity, generalized anxiety disorder, and lower levels of physical activity. In 5 of 8 reports, smaller social network size predicted depressive symptoms or disorder at follow-up. In summary, most recent relevant longitudinal studies have demonstrated that social connectedness protects adults in the general population from depressive symptoms and disorders. The results, which were largely consistent across settings, exposure measures, and populations, support efforts to improve clinical detection of high-risk patients, including adults with low social support and elevated loneliness.
Topics: Adult; Anxiety Disorders; Depression; Depressive Disorder, Major; Female; Humans; Loneliness; Mental Health; Pregnancy; Social Support
PubMed: 36228007
DOI: 10.1371/journal.pone.0275004 -
The Cochrane Database of Systematic... Feb 2021Depression 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... (Meta-Analysis)
Meta-Analysis
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.
Topics: Adolescent; Adult; Antidepressive Agents; Bias; Depression, Postpartum; Female; Humans; Patient Dropouts; Placebos; Randomized Controlled Trials as Topic; Selective Serotonin Reuptake Inhibitors; Treatment Outcome; Young Adult
PubMed: 33580709
DOI: 10.1002/14651858.CD013560.pub2