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Antidepressant treatment for postnatal
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Antidepressant treatment for postnatal depression (Review)
Molyneaux E, Howard LM, McGeown HR, Karia AM, Trevillion K
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2014, Issue 9
http://www.thecochranelibrary.com
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 2.
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Figure 3.
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Figure 4.
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Figure 5.
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DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Selective serotonin re-uptake inhibitors versus placebo, Outcome 1 Response rate at posttreatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.2. Comparison 1 Selective serotonin re-uptake inhibitors versus placebo, Outcome 2 Remission rate at posttreatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.1. Comparison 2 Antidepressants versus treatment as usual, Outcome 1 Remission rate at post-treatment.
Analysis 3.1. Comparison 3 Antidepressants versus psychosocial therapy (listening visits), Outcome 1 Remission rate at
post-treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.1. Comparison 4 Selective serotonin re-uptake inhibitors versus other pharmacological intervention (tricyclic
antidepressant), Outcome 1 Response rate at post-treatment. . . . . . . . . . . . . . . . . .
Analysis 4.2. Comparison 4 Selective serotonin re-uptake inhibitors versus other pharmacological intervention (tricyclic
antidepressant), Outcome 2 Remission rate at post-treatment. . . . . . . . . . . . . . . . . .
Analysis 5.1. Comparison 5 Sensitivity analysis: excluding trials with combined treament, Outcome 1 SSRIs verus placebo:
outcome 1.1 response rate at post-treatment. . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.2. Comparison 5 Sensitivity analysis: excluding trials with combined treament, Outcome 2 SSRIs versus placebo:
outcome 1.2 remission rate at post-treatment. . . . . . . . . . . . . . . . . . . . . . . .
Analysis 6.1. Comparison 6 Sensitivity analysis: removing studies with high dropout or high risk of bias in any domain,
Outcome 1 SSRIs verus placebo: outcome 1.1 response rate at post-treatment. . . . . . . . . . . .
Analysis 6.2. Comparison 6 Sensitivity analysis: removing studies with high dropout or high risk of bias in any domain,
Outcome 2 SSRIs versus placebo:outcome 1.2 remission rate at post-treatment. . . . . . . . . . . .
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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[Intervention Review]
Antidepressant treatment for postnatal depression
Emma Molyneaux1 , Louise M Howard1 , Helen R McGeown1 , Amar M Karia2 , Kylee Trevillion1
1 Health Service and Population Research Department, The Institute of Psychiatry, Psychology & Neuroscience, King’s College London,
London, UK. 2 School of Medicine, King’s College London, London, UK
Contact address: Louise M Howard, Health Service and Population Research Department, The Institute of Psychiatry, Psychology &
Neuroscience, King’s College London, PO31 De Crespigny Park, London, SE5 8AF, UK. louise.howard@kcl.ac.uk.
Editorial group: Cochrane Depression, Anxiety and Neurosis Group.
Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 9, 2014.
Review content assessed as up-to-date: 11 July 2014.
Citation: Molyneaux E, Howard LM, McGeown HR, Karia AM, Trevillion K. Antidepressant treatment for postnatal depression.
Cochrane Database of Systematic Reviews 2014, Issue 9. Art. No.: CD002018. DOI: 10.1002/14651858.CD002018.pub2.
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ABSTRACT
Background
Postnatal depression is a common disorder that can have adverse short- and long-term effects on maternal morbidity, the new infant
and the family as a whole. Treatment is often largely by social support and psychological interventions. It is not known whether
antidepressants are an effective and safe choice for treatment of this disorder. This review was undertaken to evaluate the effectiveness
of different antidepressants and to compare their effectiveness with other forms of treatment, placebo or treatment as usual. It is an
update of a review first published in 2001.
Objectives
To assess the effectiveness 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 the Cochrane Depression, Anxiety and Neurosis Group’s Specialized Register (CCDANCTR) to 11 July 2014. This
register contains reports of relevant randomised controlled trials (RCTs) from the following bibliographic databases: The Cochrane
Library (all years), MEDLINE (1950 to date), EMBASE, (1974 to date) and PsycINFO (1967 to date). We also searched international
trial registries and contacted pharmaceutical companies and experts in the field.
Selection criteria
We included RCTs of women with depression with onset up to six 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 trial reports. We requested missing information from investigators wherever
possible. We sought data to allow an intention-to-treat analysis. Random effects meta-analyses were conducted to pool data where
sufficient comparable studies were identified.
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
Main results
We included six trials with 596 participants in this review. All studies had a randomised controlled parallel group design, with two
conducted in the UK, three in the US and one in Israel. Meta-analyses were performed to pool data on response and remission from
studies comparing antidepressants with placebo. No meta-analyses could be conducted for other comparisons due to the small number
of trials identified.
Four studies compared selective serotonin reuptake inhibitors (SSRIs) with placebo (two using sertraline, one using paroxetine and one
using fluoxetine; 233 participants in total). In two of these studies both the experimental and placebo groups also received psychological
therapy. Pooled risk ratios based on data from three of these studies (146 participants) showed that women randomised to SSRIs had
higher rates of response and remission than those randomised to placebo (response: RR 1.43, 95% CI 1.01 to 2.03; remission: RR
1.79, 95% CI 1.08 to 2.98); the fourth study did not report data on response or remission.
One study (254 participants) compared antidepressant treatment with treatment as usual (for the first four weeks) followed by listening
visits. The study found significantly higher rates of improvement in the antidepressant group than treatment-as-usual group after the
first four weeks, but no difference between antidepressants and listening visits at the later follow-up. In addition, one study comparing
sertraline with nortriptyline (a tricyclic antidepressant) found no difference in effectiveness (109 participants).
Side effects were experienced by a substantial proportion of women, but there was no evidence of a meaningful difference in the number
of adverse effects between treatment arms in any study. There were very limited data on adverse effects experienced by breastfed infants,
with no long-term follow-up. All but one of the studies were assessed as being at high or uncertain risk of attrition bias and selective
outcome reporting. In particular, one of the placebo-controlled studies had over 50% drop-out.
Authors’ conclusions
The evidence base for this review was very limited, with a small number of studies and little information on a number of important
outcomes, particularly regarding potential effects on the child. Risk of bias, for example from high attrition rates, as well as low
representativeness of participants (e.g. exclusion of women with severe or chronic depression in several trials) also limit the conclusions
that can be drawn.
Pooled estimates for response and remission found that SSRIs were significantly more effective than placebo for women with postnatal
depression. However the quality of evidence contributing to this comparison was assessed as very low owing to the small sample size
for this comparison (146 participants from three studies), the risk of bias in included studes and the inclusion of one study where
all participants in both study arms additionally received psychological therapy. There was insufficient evidence to conclude whether,
and for whom, antidepressant or psychological/psychosocial treatments are more effective, or whether some antidepressants are more
effective or better tolerated than others. There is also inadequate evidence on whether the benefits of antidepressants persist beyond
eight weeks or whether they have short- or long-term adverse effects on breastfeeding infants.
Professionals treating women with severe depression in the postnatal period will need to draw on other evidence, including trials
among general adult populations and observational studies of antidepressant safety when breastfeeding (although the potential for
confounding in non-randomised studies must be considered). More RCTs are needed with larger sample sizes and longer follow-up,
including assessment of the impact on the child and safety of breastfeeding. Further larger-scale trials comparing antidepressants with
alternative treatment modalities are also required.
PLAIN LANGUAGE SUMMARY
Antidepressants for postnatal depression
Why is this review important?
Postnatal depression is a common disorder that can have short- and long-term adverse effects on the mother, the new infant and the
family as a whole. Antidepressants are commonly used as the first treatment option for adults with moderate to severe depression, but
there is little evidence on whether antidepressants are an effective and safe choice for the treatment of this disorder in the postnatal
period. This review was undertaken to evaluate the effectiveness of different antidepressants and to compare their effectiveness with
other forms of treatment (e.g. psychosocial interventions such as peer support, psychological interventions such as cognitive behavioural
therapy), placebo or treatment as usual.
Who will be interested in this review?
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
2
Parents, professionals in primary care services who work with women of reproductive age, general practitioners, professionals in adult
mental health services who work with women of reproductive age and professionals working in perinatal mental health services.
What questions does this review aim to answer?
This review is an update of a previous Cochrane review from 2001, which found insufficient evidence to make conclusions about
antidepressant treatment in postnatal depression. Therefore, this update aims to answer the following question:
What are the effects of antidepressants in comparison with other any other treatment, placebo or treatment as usual for postnatal
depression?
Which studies were included in the review?
We searched clinical trials registries; the Cochrane Depression, Anxiety and Neurosis Group; and the Cochrane Pregnancy and Childbirth
Group databases to find all high-quality studies comparing antidepressants with any other form of treatment from the upper date limit
of the most recent previous searches to July 2014. We contacted drug companies and experts in the field.
To be included in the review, studies had to be randomised controlled trials (clinical studies where people were randomly put into one
of two or more treatment groups) and had to include women with postnatal depression (onset of depression up to six months after
giving birth) who were not taking any antidepressant medication at the start of the trial.
We included six trials of 596 women in the review. Although many of the studies were well conducted and reported, there are some
areas with substantial risk of bias; for example, through incomplete follow-up (e.g. in one study over 50% of the participants dropped
out prior to the primary outcome measurement).
What does the evidence from the review tell us?
The quality of evidence from this review was assessed as being very low quality due to the small number of studies, risk of bias in the
included studies (in particular, high proportions of participants dropped out) and the fact that many studies excluded women with
chronic (i.e. long lasting) or severe depression, or both. We were able to combine data from three studies comparing a type of commonly
used antidepressant called selective serotonin reuptake inhibitors (SSRIs) with placebo. The results showed that women with postnatal
depression who were given SSRIs were more likely to improve or recover than those given placebo. We were unable to combine the
data from studies comparing antidepressants with other treatments or treatment as usual due to the very small number of studies
identified for these comparisons. There was insufficient evidence to conclude whether, and for whom, antidepressant or psychosocial/
psychological treatments are more effective, or whether some antidepressants are more effective or better tolerated (or both) than others.
Conclusions were also limited by the lack of data on long-term follow-up, the safety of breastfeeding or child outcomes.
What should happen next?
Larger studies need to be done, and treatment decisions for women with postnatal depression will need to use evidence from other
sources such as trials in general adult populations and observational studies of antidepressant safety in the postnatal period. The review
authors recommend that future studies in this area should include women with severe postnatal depression, long-term follow-up on
psychiatric symptoms and quality of life in mothers who have been treated for postnatal depression. In addition, more evidence is
needed on outcomes for infants, particularly with regards to the safety of breastfeeding and effect of treatment for postnatal depression
on the maternal-infant relationship.
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
3
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]
Selective serotonin reuptake inhibitors (SSRIs) compared with placebo for postnatal depression
Patient or population: women with postnatal depression
Intervention: selective serotonin reuptake inhibitors (SSRIs)
Comparison: placebo
Outcomes
Illustrative comparative risks* (95% CI)
Assumed risk
Corresponding risk
Placebo
SSRIs
Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments
Response rate at post- 365 per 10001
treatment
(as defined in individual
studies)
522 per 1000
(369 to 741)
RR 1.43 (1.01 to 2.03)
146 (3 studies)
⊕
very low2,3,4
Yonkers 2008: response:
CGI-II ≤ 2 (at 8 weeks)
Hantsoo 2013: response:
<10 HAM-D + at least
50% decrease in HAMD score from baseline +
CGI ≤ 2 (after 6 weeks of
treatment)
Bloch 2012: response: >
50% reduction in MADRS
or EPDS score during
treatment (at 8 weeks)
Remission rate at post- 257 per 10001
treatment
(as defined in individual
studies)
460 per 1000
(278 to 766)
RR 1.79 (1.08 to 2.98)
146 (3 studies)
⊕
very low2,3,4
Yonkers 2008: remission:
HAM-D ≤ 8 (at 8 weeks)
Hantsoo 2013: remission: as Hantsoo response above + HAM-D
<7
Bloch 2012: remission: final score < 10 on the
MADRS scale or <7 on
the EPDS (at 8 weeks)
4
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
*The basis for the assumed risk is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative
effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk Ratio; CGI: Clinical Global Improvement; EPDS: Edinburgh Postnatal Depression Scale; HAM-D: Hamilton Rating Scale for Depression; MADRS: MontgomeryÅsberg Depression Rating Scale
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
1 assumed
risk calculated as the proportion of women on placebo with the outcome (response or remission) in the three included studies,
multiplied by 1000.
2 downgraded due to indirectness (in one of the studies included in the meta-analysis participants in both arms additionally received
brief dynamic psychotherapy).
3 downgraded due to risk of bias (incomplete outcome data owing to loss to follow-up)
4 downgraded due to high imprecision (wide confidence intervals owing to the small number and small samples of included studies)
5
BACKGROUND
Description of the condition
Postnatal depression is an important and common disorder that
can have short- and long-term adverse impacts on the mother, her
child and the family as a whole (Letourneau 2012; Murray 1992).
Postnatal depression is characterised by persistent low mood and
loss of pleasure or interests, occurring with associated symptoms
such as changes in appetite, psychomotor agitation or retardation,
disturbed sleep and low self confidence (WHO 1992).
Both the Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) (APA 2013) and the International Classification of Disease Tenth Revision (ICD-10) (WHO 2004) include postnatal depression within the standard diagnostic criteria
for depression, and postnatal depression has been found to have
similar phenomenology to depression in women who have not recently given birth (Nylen 2013). Somatic symptoms of depression,
such as sleep disturbance and loss of libido, may occur as part of
the normative postpartum experience, but evidence suggests that
they are more commonly reported among depressed than nondepressed women in the postnatal period (with the exception of
appetite change, Nylen 2013). An onset specifier for depression is
used in both the ICD-10 (within six weeks of delivery) and DSM5 (onset during pregnancy or in the four weeks following delivery), but many researchers use time limits between three and six
months’ postpartum (Munk-Olsen 2006).
One comprehensive systematic review of perinatal depression reported a prevalence of 4.7% for major depression at three months
postpartum and 12.9% including minor (sub-threshold) depression (Gavin 2005), similar to estimates for adult women at nonchildbearing times. However, there may be an increased risk of
new episodes of depression in the period following childbirth; Cox
1993 found a three-fold increase in the incidence of depression in
the first five weeks after delivery. More recent studies using medical
records have supported a peak incidence in the first postpartum
months (Ban 2012; Munk-Olsen 2006), although it must be noted
that a substantial proportion of postnatal depression episodes begin during pregnancy or prior to conception (Wisner 2013). Most
women with postpartum depression recover within a few months
but about 30% of episodes last beyond the first postpartum year
(Goodman 2004). Women who have had postnatal depression also
have a high risk (about 40%) of both postnatal and non-postnatal
relapse (Cooper 1995; Wisner 2004).
It is important that classifications distinguish postpartum depression from both the ’baby blues’ and postpartum psychosis, which
also occur following childbirth. The ’baby blues’ are characterised
by sub-threshold symptoms of depression (e.g. insomnia, fatigue,
tearfulness, anxiety, irritability, impairment of concentration and
mood lability) occurring soon after delivery. Prevalence estimates
range from 15% to 85% among postpartum women (often around
50%, Henshaw 2003), but symptoms are usually mild and resolve
within days. In contrast, postpartum psychosis is a very severe condition that affects a small proportion of postpartum women (about
2 per 1000) (Kendell 1987). Women with postpartum psychosis
may present with mania, psychotic depression, schizophrenia or
confusional states and in most cases, hospitalisation is indicated.
Description of the intervention
In light of the influence of social factors, psychosocial and psychological interventions to improve outcomes for women with postnatal depression have been developed and evaluated. Reductions in
depression have been identified following a range of psychosocial
and psychological interventions (e.g. non-directive counselling,
telephone-based peer support and cognitive behavioural therapy
(CBT)) compared with usual care (Dennis 2013). However, for
some women who cannot access psychosocial or psychological interventions or who have a severe depression, antidepressant drugs
may be an important alternative form of treatment.
Antidepressants are drugs that treat the symptoms of depression.
They are commonly used as the first treatment option for adults
with moderate to severe depression, and can be classified into the
following types:
• selective serotonin re-uptake inhibitors (SSRIs, e.g.
fluoxetine) selectively block the re-uptake of serotonin. They are
less dangerous in terms of overdose than most tricyclic
antidepressants (TCA);
• TCAs (e.g. amitriptyline) are antimuscarinic drugs that
block the re-uptake of both serotonin and noradrenaline
(norepinephrine) and have variable sedating properties;
• heterocyclic antidepressants (e.g. mianserin), which block
the re-uptake of noradrenaline and serotonin (5-HT);
• monoamine oxidase inhibitors (MAOIs, e.g. phenelzine):
most drugs from this class are not commonly used due to the
dangerous reactions these drugs have with various food groups
and other drugs. They act by causing an accumulation of amine
neurotransmitters;
• noradrenaline re-uptake inhibitors (NARIs, e.g.
reboxetine);
• noradrenaline-dopamine re-uptake inhibitors (NDRIs,
e.g. amineptine, buproprion);
• serotonin-noradrenaline re-uptake inhibitors (SNRIs,
e.g. duloxetine, milnacipram, venlafaxine);
• noradrenergic and specific serotonergic antidepressants
(NASSAs, e.g. mirtazapine);
• serotonin antagonist and re-uptake inhibitors (SARIs,
e.g. trazodone);
• other unclassified antidepressants (e.g. agomelatine,
vilazodone).
Antidepressants - and often their metabolites (especially if pharmacologically active) - are lipid soluble and are excreted in breast
milk. These drugs are metabolised mainly in the liver and excreted
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
6
via the kidneys. Exposure to antidepressants in breastfed infants is
considerably lower (five- to 10-fold) than exposure in utero (Berle
2011), but immaturity or impairment of liver or kidneys (e.g. in
preterm babies) may lead to higher concentrations. Breastfeeding
women are advised to avoid doxepin (a TCA) as its main metabolite
has been found in higher concentrations (Eberhard-Gran 2006).
Some case reports and case series have described non-specific adverse events in infants exposed to other antidepressants through
breastfeeding, most commonly following exposure to fluoxetine
(e.g. poor feeding) and citalopram (e.g. poor sleep) (Berle 2011).
There is no evidence of longer-term adverse outcomes among infants exposed to antidepressants (Berle 2011), but this could reflect a lack of studies.
Due to the limitations of the existing evidence, most manufacturers’ data sheets carry warnings that antidepressants should not
be given to nursing mothers. Physicians often advise women not
to breastfeed when taking an antidepressant or may prescribe reduced and potentially ineffective doses or delay pharmacotherapy
until after breastfeeding. However, most researchers agree that if
a mother was successfully treated for depression during her pregnancy, the same medication should usually be used in the postpartum period while breastfeeding as discontinuing or switching an
antidepressant treatment could lead to relapse.
antidepressant drugs in the postnatal period and it is important to
establish the effectiveness of antidepressant drugs in comparison
with other forms of treatment for postnatal depression or placebo.
In addition, although antidepressants are lipid soluble and are excreted in breast milk, the safety of breastfeeding while taking these
medications has not been sufficiently reviewed. There is some evidence to suggest that the benefits of breastfeeding may outweigh
potential risks for healthy infants born at term (Berle 2011).
Although beyond the scope of this review, antidepressants may
also be used for the treatment of pre-existing and antenatal depression during pregnancy. One forthcoming Cochrane review will
complement this review by examining the effectiveness of antidepressant use, compared with placebo or psychological therapy, for
the treatment of pre-existing and antenatal depression (Gordon
2013).
OBJECTIVES
To assess the effectiveness of antidepressant drugs in comparison
with any other treatment (psychological, psychosocial or pharmacological), placebo or treatment as usual for postnatal depression.
How the intervention might work
There is substantial evidence showing the effectiveness of antidepressants for depression, particularly as severity of depression increases (Fournier 2010); however, the exact mechanism by which
antidepressants have their effect is unclear. One systematic review and meta-analysis of pharmacological neuroimaging studies
found that, for both patients and healthy controls, repeated antidepressant administration affected activity in areas of the medial prefrontal cortex and limbic systematic that are associated
with emotion processing (e.g. the anterior cingulate, amygdala
and thalamus), with increased activity in response to positive
emotions and decreased activity in response to negative emotions
(Ma 2014). It appears that most antidepressants inhibit uptake
of monoamine neurotransmitters (e.g. serotonin or noradrenaline
(norepinephrine)) into neurons thereby increasing the concentrations of these neurotransmitters at synapses (Berton 2006). However, there is some debate over the therapeutic mechanism due to
the delay before an antidepressant effect occurs (Pringle 2011).
METHODS
Criteria for considering studies for this review
Types of studies
We included all published and unpublished randomised controlled
trials (RCTs) and cluster RCTs comparing antidepressant drugs
with any other treatment, placebo or treatment as usual for postnatal depression. We included trials employing a cross-over design.
We excluded all other study designs, including quasi-randomised
studies and non-randomised studies.
Types of participants
Why it is important to do this review
Postnatal depression is a common problem that can have adverse
short- and long-term effects on the mother, her child and the
wider family. Antidepressants are commonly used as the first treatment option for adults with moderate to severe depression (NICE
2007), but there are few systematic data on the effectiveness of
Participant characteristics
Women of any age with postnatal depression (onset up to six
months after giving birth) who were enrolled into a trial and who
were not taking any antidepressant medication at the start of the
trial.
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
7
Diagnosis
Comparator intervention
We used a broad definition of postnatal depression to include all
women who were depressed during the first six months’ postpartum regardless of time of onset. Thus, women were included who
met criteria for depression by any of the following: use of a validated screening measure, for example, the Edinburgh Postnatal
Depression Scale (EPDS) (Cox 1987), use of standard observerrated depression diagnostic instrument, by a recognised diagnostic scheme (e.g. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (APA 1999) or the ICD-10
(WHO 1992), or by other standardised criteria, for example, the
Research Diagnostic Criteria (RDC) (Spitzer 1978). The threshold scores used for the respective scales were those used by the
investigators in the trials.
Any other treatment, placebo or treatment as usual. We included
other treatments such as psychological interventions (e.g. CBT or
interpersonal therapy), psychosocial interventions (e.g. peer support or non-directive counselling) or other pharmacological interventions (e.g. another antidepressant).
Co-morbidities
Studies involving participants with co-morbid physical conditions
or other psychological disorders (e.g. anxiety) were eligible for
inclusion as long as the co-morbidity was not the focus of the
study.
Setting
Types of outcome measures
We included studies that met the above inclusion criteria regardless
of whether they reported on the following outcomes.
Primary outcomes
1. Response or remission of depression, using defined
dichotomous response, remission or improvement as reported in
the individual studies.
2. Adverse events (or side effects) experienced by:
i) mother (e.g. headaches, diarrhoea, nausea);
ii) nursing baby (e.g. respiratory depression, poor sleep,
poor feeding).
We extracted all adverse events and data from side effect scales
(e.g. Asberg Side Effects Rating Scale) recorded in the trial reports
and summarised them narratively. We also reported overall proportions of participants experiencing adverse effects by trial arm
where possible.
We assigned no restrictions to the type of study setting.
Secondary outcomes
Types of interventions
Experimental intervention
Antidepressant medication alone or in combination with another
antidepressant or treatment, initiated in at least one arm of a trial.
Antidepressants were organised into classes for the purposes of this
review, for example:
• SSRIs: citalopram, escitalopram, fluoxetine, fluvoxamine,
paroxetine, sertraline;
• TCAs: amitriptyline, clomipramine, desipramine,
dothiepin, doxepin, imipramine, lofepramine, nortriptyline,
protriptyline, trimipramine;
• heterocyclic antidepressants: mianserin;
• MAOIs:irreversible: izocarboxazid, phenelzine,
tranylcipromine; reversible: brofaramine, moclobemide, tyrima;
• NARIs: reboxetine;
• NDRIs: amineptine, buproprion;
• SNRIs: duloxetine, milnacipram, venlafaxine;
• NASSAs: mirtazapine;
• SARIs: trazodone;
• other unclassified antidepressants: agomelatine,
vilazodone.
1. Severity of depression based on rating scales (continuous
data; either self reported, such as the EPDS, or clinician rated,
such as the Inventory of Depression Severity (Clinician Rated
Version)).
2. Acceptability of treatment both as assessed directly by
questioning trial participants and indirectly by the dropout rates.
3. Cognitive development of the infant/child (e.g. assessment
of the mental and psychomotor development of infants using the
Mental Development Index (MDI) and Psychomotor
Development Index (PDI) of the Bayley Scales of Infant
Development (Bayley 2006); parent reports of developmental
assessment of children aged two to three years using the Parent
Report of Children’s Abilities-Revised (PARCA-R) (Johnson
2008); measure of intellectual ability among children aged six
years and above using the Wechsler Intelligence Scale for
Children (Wechsler 1974)).
4. Overall maternal satisfaction (e.g. self report general
satisfaction, satisfaction with self/baby/partner using the Mackay
Childbirth Satisfaction Rating Scale (Goodman 2004); self
report beliefs, values and perceived skills regarding motherhood
using the Parenting Sense of Competence Scale
(Gidaud-Wallston 1978)).
5. Maternal relationship with the baby (e.g. improved motherinfant interactions measured using the CARE-Index (Crittenden
1988)).
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6. Ability of the mother to carry out daily activities and in her
social functioning (e.g. improved score on the Global Assessment
of Functioning Scale (Endicott 1976); increased social network,
measured using the Social Network Index (Cohen 1997)).
7. The establishment or continuation of breastfeeding (e.g.
rates of establishment, continuation or discontinuation).
8. Neglect or abuse of the baby (e.g. using the Parent-Report
Multidimensional Neglectful Behavior Scale (Kaufman Kantor
2004)).
9. The effect on marital and family relationships (e.g. using
the Quality of Marriage Index (Norton 1983)).
10. Quality of life (e.g. using the 36-item Short Form (SF-36)
(Ware 1992)).
Timing of outcome assessment
•
•
•
•
Zero to eight weeks - immediate effects.
Nine to 16 weeks - short-term effects.
17 to 24 weeks - intermediate effects.
More than 24 weeks - long-term effects.
Search methods for identification of studies
We identified all studies that might describe RCTs of antidepressants for postnatal depression from the Depression, Anxiety and Neurosis Cochrane Review Group Trials Registers (CCDANCTR) (most recent search, 11th July 2014).
The Cochrane Depression, Anxiety and Neurosis
Review Group’s Specialised Register (CCDANCTR)
The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) maintain two clinical trials registers at their editorial base in
Bristol, UK: a references register and a studies-based register. The
CCDANCTR-References Register contains over 35,000 reports
of RCTs in depression, anxiety and neurosis. Approximately 60%
of these references have been tagged to individual, coded trials.
The coded trials are held in the CCDANCTR-Studies Register
and records are linked between the two registers through the use
of unique Study ID tags. Coding of trials is based on the EU-Psi
coding manual, using a controlled vocabulary, please contact the
CCDAN Trials Search Coordinator for further details. Reports
of trials for inclusion in the Group’s registers are collated from
routine (weekly), generic searches of MEDLINE (1950-), EMBASE (1974-) and PsycINFO (1967-); quarterly searches of the
Cochrane Central Register of Controlled Trials (CENTRAL) and
review specific searches of additional databases. Reports of trials
are also sourced from international trials registers c/o the World
Health Organization’s trials portal (the International Clinical Trials Registry Platform (ICTRP)), pharmaceutical companies, the
handsearching of key journals, conference proceedings and other
(non-Cochrane) systematic reviews and meta-analyses.
Details of CCDAN’s generic search strategies (used to identify
RCTs) can be found on the Group’s website.
Electronic searches
1.The CCDANCTR (Studies and Reference Registers) was
searched (to 11th July 2014) using the following terms, on the
new Cochrane Register of Studies (CRS) platform:
#1 (antidepress* or anti-depress* or “anti depress*” or MAOI* or
RIMA* or “monoamine oxidase inhibit*” or ((serotonin or norepinephrine or noradrenaline or neurotransmitter* or dopamin*)
NEAR (uptake or reuptake or re-uptake or “re uptake”)) or SSRI*
or SNRI* or NARI* or SARI* or NDRI* or TCA* or tricyclic* or
tetracyclic* or pharmacotherap* or psychotropic* or “drug therapy”)
#2 (agomelatine or alaproclate or amoxapine or amineptine or
amitriptylin* or amitriptylinoxide or atomoxetine or befloxatone
or benactyzine or binospirone or brofaromine or (buproprion or
amfebutamone) or butriptyline or caroxazone or cianopramine or
cilobamine or cimoxatone or citalopram or (chlorimipramin* or
clomipramin* or chlomipramin* or clomipramine) or clorgyline
or clovoxamine or (CX157 or tyrima) or demexiptiline or deprenyl
or (desipramine* or pertofrane) or desvenlafaxine or dibenzepin or
diclofensine or dimetacrin* or dosulepin or dothiepin or doxepin
or duloxetine or desvenlafaxine or DVS-233 or escitalopram or
etoperidone or femoxetine or fluotracen or fluoxetine or fluvoxamine or (hyperforin or hypericum or “st john*”) or imipramin*
or iprindole or iproniazid* or ipsapirone or isocarboxazid* or levomilnacipran or lofepramine* or (“Lu AA21004” or vortioxetine)
or “Lu AA24530” or (LY2216684 or edivoxetine) or maprotiline or melitracen or metapramine or mianserin or milnacipran
or minaprine or mirtazapine or moclobemide or nefazodone or
nialamide or nitroxazepine or nomifensine or norfenfluramine or
nortriptylin* or noxiptilin* or opipramol or oxaflozane or paroxetine or phenelzine or pheniprazine or pipofezine or pirlindole or
pivagabine or pizotyline or propizepine or protriptylin* or quinupramine or reboxetine or rolipram or scopolamine or selegiline or
sertraline or setiptiline or teciptiline or thozalinone or tianeptin*
or toloxatone or tranylcypromin* or trazodone or trimipramine or
venlafaxine or viloxazine or vilazodone or viqualine or zalospirone)
#3 (#1 or #2)
#4 (postpartum or post-partum or “post partum” or postnatal* or
post-natal* or “post natal*” or perinatal* or peri-natal* or “peri
natal*” or puerp* or intrapartum or intra-partum or “intra partum”
or antepartum or ante-partum or “ante partum”)
#5 (pregnan* or maternity or birth or prenatal* or pre-natal* or
“pre natal*” or antenatal* or ante-natal* or “ante natal*”) and
depress*
#6 (#4 or #5)
#7 (#3 and #6)
Records were screened by the Trials Search Co-ordinator(TSC)
to remove irrelevant records (eg trials for major depression where
pregnancy was an exclusion criteria).
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No restriction on date, language or publication status was applied
to the search. Where potentially relevant papers were identified
that did not have English language full-text versions, translations
were requested from contacts of the review authors or the editorial
team of the Cochrane Depression, Anxiety and Neurosis group.
2. The Cochrane Pregnancy and Childbirth Group’s
Specilaized Register was also searched (25th Oct 2013) using
terms for antidepressants (as listed above).
No additional studies were identified by this search, so updates
were restricted to the CCDANCTR.
3.International Trials Registries
ClinicalTrials.gov and the WHO trials portal were searched on
11th July 2014 to identify ongoing and/or unpublished studies.
Searching other resources
Reference lists
Forward and backward citation tracking of all included studies was
carried out to identify additional studies missed from the original
electronic searches (for example unpublished or in-press citations).
Personal communication
The following Pharmaceutical companies were contacted directly
for any relevant unpublished data: Pfizer, Roche, Astrazeneca,
Abbott, Lilly, Bayer, GSK, Sanofi, Rosemont pharma, Johnson & Johnson, Merck, Novartis, Teva, Alliance, Amdipharm,
Dallas Burston Ashbourne, Lundbeck, Abbvie, Alcon, Brittannia Pharmaceuticals Lts, Cox Pharma, Crawford Pharmaceuticals, De Novo Pharmaceuticals, ECRON, Valeant, Viastris, BHR
Pharma, Actavis, Forest Pharmaceuticals, Mitsubishi Pharmaceuticals, Ranbaxy, Bristol Myers-Squibb (responses received from:
Lilly, Sanofi, Johnson & Johnson, Merck, Teva, Lundbeck, Mylan,
Actavis and Bristol Myers-Squibb).
Contact was made with authors of identified trials and with experts in the field (Professor Lee Cohen, Dr Kimberly A. Yonkers,
Professor Philip Boyce, Professor Katherine Wisner, Professor Ian
Jones, Professor Salvatore Gentile).
The International Marcé Society was also contacted.
Data collection and analysis
Selection of studies
Two of three review authors (KT, HM or AK) independently inspected abstracts retrieved from the search. We obtained the fulltext articles for any publication that was potentially relevant. Two
authors independently assessed the full articles for inclusion based
on the previously defined inclusion criteria. We resolved any disagreements by consensus discussions with an additional review author (EM). If it was impossible to resolve disagreements, we contacted the authors of the papers for clarification.
The review authors excluded duplicate records and recorded reasons for exclusion of ineligible studies (see Characteristics of
excluded studies table). We collated multiple reports that related
to the same study so that each study rather than each report was
the unit of interest in the review. We recorded the selection processes in sufficient detail to complete a PRISMA flow diagram and
Characteristics of included studies table.
We processed included trial data as described in the Cochrane
Handbook for Systematic Reviews of Interventions (Higgins 2011),
and the guidelines issued by the National Health Service (NHS)
Centre for Reviews and Dissemination (Centre for Research and
Dissemination 2009).
Data extraction and management
The review authors designed and piloted a data extraction form,
based on the following study characteristics.
1. Methods: date of study, study design, study setting, details
of blinding/allocation concealment, total duration of study,
details of any ’run-in’ period, number of study centres and
location, and withdrawals.
2. Participants: total number and number of each group,
inclusion and exclusion criteria, mean age, age range, severity of
condition and diagnostic criteria.
3. Interventions: number of intervention groups, type of
interventions and comparisons, duration of intervention and key
details (e.g. dosage, adherence, quality of delivery), concomitant
medications and excluded medications.
4. Outcomes: details of measures used to assess outcomes (e.g.
details of validation), primary and secondary outcomes specified
and collected, time points reported and adverse events.
5. Analysis: statistical techniques used, unit of analysis for
each outcome, subgroup analyses, number of participants
followed up from each condition.
6. Notes: publication type, funding for trial and notable
conflicts of interest of trial authors.
Two review authors (HM and AK) independently extracted data
from included studies into standard paper or electronic forms. We
checked all data for consistency and resolved any disagreements
by going back to the original papers, and by discussion with a
third review author (EM or KT) where necessary. If necessary, we
contacted authors of the studies for clarification or when inadequate details of randomisation and other characteristics of trials
were provided.
One review author (KT) transferred data into Review Manager 5 (
RevMan 2012), which was then double-checked by comparing the
data presented in the systematic review with the study reports. A
second review author (EM) also spot-checked study characteristics
for accuracy against the trial report.
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Main comparisons
The main planned comparisons were as follows:
1. Antidepressants versus placebo;
2. Antidepressants versus treatment as usual;
3. Antidepressants versus psychological intervention;
4. Antidepressants versus psychosocial intervention;
5. Antidepressants versus other pharmacological intervention.
We had planned to include antidepressants versus psychological
intervention, but no included studies provided data for this. We
also planned to present comparisons on a drug level; however, due
to the amount of data available, comparisons were combined by
class of drug (see Types of interventions).
Assessment of risk of bias in included studies
Three review authors (HM, AK and EM) independently assessed
risk of bias for each study using the criteria outlined in the Cochrane
Handbook for Systematic Reviews of Interventions (Higgins 2011).
The three review authors resolved any disagreements by discussion
or by involving another review author (KT). We assessed risk of
bias according to the following domains.
1. Random sequence generation.
2. Allocation concealment.
3. Blinding of participants and personnel.
4. Blinding of outcome assessment.
5. Incomplete outcome data.
6. Selective outcome reporting.
7. Other bias (adherence to medication).
We judged each potential source of bias as high, low or unclear and
included a supporting quotation from the study report together
with a justification for the review authors judgement in the ’Risk
of bias’ table. We summarised the risk of bias judgements across
different studies for each of the domains listed. Where information
on risk of bias related to unpublished data or correspondence with
a trialist, we noted this in the ’Risk of bias’ table.
Measures of treatment effect
We presented the primary outcome of depression response or remission using risk ratios (RR) for all studies. We summarised other
outcomes using the data as quoted in the original papers (e.g. odds
ratio (OR), RR, mean difference (MD)). If there were sufficient
data for meta-analyses to be performed on any outcomes, we calculated RRs for dichotomous outcomes and MDs or standardised
mean difference (SMD) for continuous data.
Dichotomous data
We calculated the RR and its 95% confidence interval (CI) for
primary outcome dichotomous data. It has been shown that RR
is more intuitive than ORs and that OR tend to be interpreted as
RR by clinicians (Bland 2000). This misinterpretation then leads
to an overestimate of the impression of the effect.
Where possible, we attempted to convert outcome measures to
dichotomous data using cut-off points on rating scales to identify
those who did and did not fulfil the criteria for depression.
Continuous data
If a meta-analysis was conducted for continuous data, we would
analyse this by calculating the MD between groups, if studies
use the same outcome measure for comparison. If studies used
different outcome measures to assess the same outcome, we would
calculate SMD and 95% CIs.
When standard errors instead of standard deviations (SD) were
presented, we converted the former to SDs. If SDs were not reported and could not be calculated from available data, we asked
authors to supply the data. In the absence of data from authors,
we used the mean SD from other studies.
Unit of analysis issues
Cluster-randomised trials
It is important to ensure that the data analysed from cluster RCTs
takes into account the clustered nature of the data. No clusterRCTs met the inclusion criteria for this review, but if any are included in future updates we will deal with them as follows. We will
extract the intra-cluster correlation coefficient (ICC) for each trial;
where no such data are reported, we will request the information
from study authors. If this information is not available, in line
with the Cochrane Handbook for Systematic Reviews of Interventions
(Higgins 2011), we will use estimates from similar studies in order
to ’correct’ data for clustering, where this had not been done. We
will use generic inverse variance methods to meta-analyse results
from cluster RCTs (Higgins 2011).
Cross-over trials
A major concern of cross-over trials is the carry-over effect. It
occurs if an effect (e.g. pharmacological or psychological) of the
treatment in the first phase is carried over to the second phase.
As a consequence, on entry to the second phase the participants
can differ systematically from their initial state despite a wash-out
phase. For the same reason, cross-over trials are not appropriate
if the condition of interest is unstable (Elbourne 2002). Both of
these effects are very likely in postnatal depression; although we
identified no cross-over trials in the review, if any are identified
for inclusion in future updates we will only use data from the first
randomised treatment period.
Studies with multiple treatment groups
Trials that have more than two arms (e.g. pharmacological intervention (A); psychological intervention (B); and control (C))
can cause issues with regards to pair-wise meta-analysis. In line
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with the Cochrane Handbook for Systematic Reviews of Interventions
(Higgins 2011), if we identified any studies with two or more active treatment arms, then we took the following approach, dependent on whether the outcome was dichotomous or continuous:
For a dichotomous outcome: we combined active treatment groups
into a single arm for comparison against the control group (in
relation to the number of people with events and sample sizes), or
the control group was split equally.
For a continuous outcome: we pooled means, SDs and the number
of participants for each active treatment group across treatment
arms as a function of the number of participants in each arm to
be compared against the control group.
• 30% to 60% may represent moderate heterogeneity;
• 50% to 90% may represent substantial heterogeneity;
• 75% to 100% represents considerable heterogeneity;
We interpreted the I2 value using the results of the Chi2 test as
well as the magnitude of the pooled effect size.
Assessment of reporting biases
Had there been more than 10 included studies, we would have
generated a funnel plot and visually inspected it for asymmetry.
Asymmetry in the plot could be attributed to publication bias;
however, there are other causes of funnel plot asymmetry that we
would have also considered.
Dealing with missing data
At some degree of loss of follow-up, data must lose credibility (Xia
2009); therefore, in the protocol, we determined that we would
exclude studies with more than 50% loss to follow-up.
In the case where attrition for a binary outcome was between 0%
and 50% and outcomes for these people were presented, we reported the data. We presented data on a ’once-randomised alwaysanalyse’ basis, assuming an intention-to-treat (ITT) analysis. We
assumed that women lost to follow-up had a negative outcome,
with the exception of the outcome of death. For example, for the
outcome of remission of depression, we assumed that this had not
occurred for any of the women lost to follow-up.
In the case where attrition for a continuous outcome was between
0% and 50% and completer-only data were reported, we reproduced these.
We used ITT analysis when available. It was anticipated that some
studies would have used the method of last observation carried
forward (LOCF) to do an ITT analysis. As with all methods of
imputation to deal with missing data, LOCF introduces uncertainty about the reliability of the results. Therefore, where we have
reported LOCF data in this review it is indicated. We presented
ITT analysis for all primary outcomes. Where ITT analyses were
not available for secondary outcomes, we reported this in the relevant section of the results.
Assessment of heterogeneity
If there were sufficient data for a meta-analysis, we assessed statistical heterogeneity visually by studying the degree of overlap of the
CIs for individual studies in a forest plot. We also carried out more
formal assessments using a Chi2 test with the P value set at 0.1 and
the I2 statistic, as the Chi2 test has low power to detect diversity
when the number of studies is low or sample size is small. The I
2 statistic only provides an approximate estimate of the variability
due to heterogeneity so the following overlapping bands would
be used to guide our interpretation of the I2 statistic, as suggested
in the Cochrane Handbook for Systematic Reviews of Interventions
(Higgins 2011):
• 0% to 40% might not be important;
Data synthesis
We planned a random-effects meta-analysis to synthesise data from
studies with comparable methods (using the same class of antidepressants and the same comparison group, e.g. placebo, listening
visits) if three or more studies were identified for each comparison.
Subgroup analysis and investigation of heterogeneity
We planned subgroup analyses to assess the effectiveness of the
intervention in the following groups:
1. women with mild to moderate depressive disorder (as
defined by diagnostic interview or a validated scale) versus
women with severe depressive disorder (as defined by diagnostic
interview or a validated scale);
2. women with chronic depression (onset pre-pregnancy)
versus women with onset in pregnancy versus new-onset
postpartum depression;
3. interventions lasting eight weeks or less versus interventions
lasting more than eight weeks.
Sensitivity analysis
We planned a priori sensitivity analyses (if sufficient data were
identified) to explore the robustness of pooled estimates to decisions made in the systematic review. The effect of excluding studies with the following characteristics was assessed:
1. study quality: excluding studies that had a high risk of bias
in any domain;
2. blinding: excluding antidepressant versus placebo trial
studies that were unblinded;
3. attrition: excluding studies with more than 20% drop-out.
Based on the change to the protocol (see below and Differences
between protocol and review), we also planned a second
sensitivity analysis for attrition excluding studies with greater
than 50% attrition;
4. validation: excluding outcomes based on non-validated
scales from the analyses.
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For outcomes with both skewed data and non-skewed data, we
investigated the effect of combining all data together and if there
was no substantive difference then we left the potentially skewed
data in the analyses.
Summary tables
We produced summary tables for the key findings of the review for
all main comparisons. The tables present the findings for remission and response with outcomes for individual trials and pooled
estimates, where calculated.
RESULTS
Description of studies
Results of the search
We conducted searches to July 2014 retrieving 134 references from
the specialised registers of the two Cochrane Review Groups (CCDAN and PCG). We retrieved an additional 428 records from
other sources, including nine studies suggested by pharmaceutical
companies. After de-duplication, two review authors (HM, AK or
KT) independently screened 382 records and excluded 361 records
(on title and abstract) as they did not meet the inclusion criteria.
We retrieved the full-text papers for the remaining 21 reports and
assessed them for eligibility. After discussion, the review authors
decided that the protocol should be altered to allow studies with
more than 50% attrition rate to be included in the review due
to the small number of relevant RCTs. Therefore, we included
Yonkers 2008 (56% dropout).
We required further information to determine the eligibility of one
study (Wisner 2006); the trial investigator provided this (Katherine Wisner). Information on antidepressant prescriptions in Sharp
2010 was also provided following contact with the study author
(Debbie Sharp). We translated the two Chinese papers, but neither
was eligible for the review. Forward and backward citation tracking
of included articles yielded no further relevant trials. The PRISMA
flow diagram details the study selection process (see Figure 1).
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Figure 1. Study selection flow diagram.
Antidepressant treatment for postnatal depression (Review)
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Six trials met the inclusion criteria and were included in the review. We also identified one potentially eligible on-going study
(NCT00602355) and two studies awaiting classification with
no data available at the time of production of this review
(NCT00744328; NCT02122393). More detail on these studies is given in the Characteristics of ongoing studies table and
Characteristics of studies awaiting classification tables.
Included studies
We included six trials in this updated review (see Characteristics
of included studies table).
Design
All included studies used a randomised controlled parallel groups
design. We identified no eligible cluster-randomised or cross-over
trials.
Sample sizes
The study by Sharp 2010 had the largest study population with
254 participants randomised. A total of 109 women participated
in Wisner 2006, 87 in Appleby 1997, 70 in Yonkers 2008, and
36 in Hantsoo 2013. We included 40 participants from the Bloch
2012 study (42 were randomised but two withdrew immediately
following randomisation and were not included in the ITT analysis). The total number of participants included in the review was
596.
Setting
Two studies took place in the UK (Appleby 1997; Sharp 2010),
three in the US (Hantsoo 2013; Wisner 2006; Yonkers 2008), and
one in Israel (Bloch 2012).
Participants
The studies had broadly similar inclusion and exclusion criteria.
All required women to meet criteria for depression in the postpartum period, although different criteria were used between studies. Bloch 2012 and Hantsoo 2013 both assessed depression using the Structured Clinical Interview for DSM-IV; Hantsoo 2013
also requiring participants to score 18 or greater on the Hamilton
Rating Scale for Depression (HAM-D) at study entry and to have
symptoms rated as at least ’moderate’ of the Global Clinical Impressions (CGI) severity of illness scale. Wisner 2006 and Yonkers
2008 both required participants to meet the DSM-IV criteria for
major depressive disorder and score above a cut-off on the HAMD (18 or greater for Wisner 2006 and 16 or greater for Yonkers
2008). Sharp 2010 assessed depression using the Revised Clinical
Interview Schedule (CIS-R) for ICD-10 and the EPDS (participants had to score 13 or greater at entry to the study). Appleby
1997 required women to score 10 or greater on the EPDS and 12
or greater on the CIS-R, as well as satisfying researcher diagnostic criteria for major or minor depression (see Characteristics of
included studies for more details on these measures).
Enrolment times varied between six to eight weeks’ postpartum
(Appleby 1997), and within 12 months’ postpartum (Hantsoo
2013). In all studies, onset of the depressive episode had to be
before six months’ postpartum (ranging from four weeks’ postpartum (Wisner 2006), to 26 weeks’ postpartum (Sharp 2010)). In
all included trials, participants were not taking any antidepressant
medication at the commencement of the study. In three trials, participants were also not eligible for the study if they were receiving
psychological therapy (Sharp 2010; Wisner 2006; Yonkers 2008).
All studies restricted the population of depressed women with
further exclusion criteria. In order to restrict the participants to
women with moderate depression, women were excluded from the
Hantsoo 2013 study if they scored 32 or greater on the HAM-D
and from Bloch 2012 if they scored 30 or greater on the Montgomery-Åsbery Depression Rating Scale (MADRS). Four studies excluded women with suicidal ideation (Bloch 2012; Hantsoo
2013; Sharp 2010; Yonkers 2008). Four studies also excluded
women based on the duration of existing symptoms of depression
(over two years: Appleby 1997; over six months: Bloch 2012; onset
of major depressive disorder during pregnancy or before: Hantsoo
2013; Yonkers 2008). Sharp 2010 did not exclude women based
on length of depressive episode and Wisner 2006 also included
women with chronic depression (defined as an episode of major
depression that began before the index pregnancy), but only after
additional funding was obtained part way through the trial.
Three studies excluded women with treatment-resistant depression (Appleby 1997; Bloch 2012; Hantsoo 2013), defined as two
failed trials of antidepressants by Bloch 2012, and past failed
trial of sertraline by Hantsoo 2013. Five studies excluded women
with current alcohol or drug misuse (Appleby 1997; Bloch 2012;
Hantsoo 2013; Sharp 2010; Yonkers 2008), and five studies excluded women with current or past psychotic symptoms or disorders (such as bipolar disorder, schizophrenia or schizoaffective
disorder)(Bloch 2012; Hantsoo 2013; Sharp 2010; Wisner 2006;
Yonkers 2008). Appleby 1997 excluded any women with severe
illness. Three studies stated that they excluded women with major physical illness (Appleby 1997; Bloch 2012; Hantsoo 2013),
and one study excluded mothers who were breastfeeding (Appleby
1997).
Where age inclusion criteria were stated, these were largely 18+ or
18 to 45 years (Bloch 2012; Hantsoo 2013; Sharp 2010); however,
Yonkers 2008 included women from 16 years of age and Wisner
2006 included women from 15 years. Where mean age was re-
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ported in studies, this ranged from 23.1 years (Appleby 1997, in
the placebo plus one session of counselling group) to 30.8 ± 4.0
years (Hantsoo 2013).
The predominant ethnicity was reported was white, ranging from
48.6% of participants in the study by Yonkers 2008 to 94.4% of
participants in the Hantsoo 2013 study. In one study, there was
a significant minority of Hispanic participants (35.7%) (Yonkers
2008), with a small minority of participants in the study by
Hantsoo 2013 being Hispanic (5.6%). Two studies had a minority of black participants (12.9%: Yonkers 2008; 11.5%: Sharp
2010), and the study by Sharp 2010 also had 13 Asian participants
(5.2% of those randomised). In the study by Wisner 2006, 40% of
women randomised to sertraline and 19% of women randomised
to nortriptyline had non-white ethnicity. Two studies provided
no data on ethnicity (Bloch 2012, Appleby 1997). Information
provided on socioeconomic status was highly varied, making any
comparisons of socioeconomic status across trials difficult.
All studies assessed severity of depression at baseline. Wisner 2006
reported that baseline severity was assessed using several scales including the HAM-D and CGI with no difference between the
two study groups, but did not report scale scores. Appleby 1997
reported geometric means scores on the EPDS and the HAMD for all women randomised to take fluoxetine (all also receiving either one or six sessions of counselling) and all women randomised to placebo (again all also receiving either one or six sessions of counselling). Geometric mean HAM-D scores were 14.2
(95% CI 13.0 to 15.5) for the fluoxetine group and 13.9 (95%
CI 12.5 to 15.4) for the placebo group; on the HAM-D scores in
the range 8 to 16 indicate mild depression (Zimmerman 2013),
Geometric mean EPDS scores were 17.2 (95% CI 16.2 to 18.2)
for the fluoxetine group and 16.9 (95% CI 15.8 to 18.1) for the
placebo group. In Bloch 2012, baseline EPDS scores showed similar means to Appleby 1997 with 16.05 (SD 4.84) in the brief
dynamic psychotherapy group plus placebo group and 18.40 (SD
4.83) in the brief dynamic psychotherapy group plus antidepressant group. Similar baseline severity was also found in the Sharp
2010 study based on EPDS scores (mean ± SD: 17.3 ± 3.3 for
the antidepressant group and 17.7 ± 3.5 for the treatment as usual
followed by listening visits group).
Higher baseline severity was found in two placebo-controlled
studies (mean HAM-D scores in the range 17 to 23 indicating ’moderate depression’ and ≥24 indicating ’severe depression’;
Zimmerman 2013). Hantsoo 2013 measured baseline severity
with both the EPDS and HAM-D; on the EPDS the mean score
for women randomised to the antidepressants (sertraline) was 18.8
(SD 2.6) and 20.8 (SD 5.7) for women randomised to placebo.
On the HAM-D, these scores were 20.6 (SD 2.8) for the antidepressant group and 23.2 (SD 3.9) for the placebo group. Similar
but slightly higher scores were recorded at baseline by Yonkers
2008; in this study women randomised to antidepressants had a
mean HAM-D score of 23.6 (SD 4.7) and women randomised to
placebo had a mean HAM-D score of 24.7 (SD 5.0). Further de-
tails on these measures are given in the Characteristics of included
studies table.
Women were recruited from a variety of settings, including general practice, postnatal wards, obstetric care settings and general
advertising. Sharp 2010 sent an information pack containing an
EPDS questionnaire to all new mothers within the catchment area
(data obtained from birth registry office and general practitioner
(GP) records). The length of the recruitment period ranged from
20 months (Appleby 1997) to 10 years (Hantsoo 2013) (not described in Wisner 2006).
Interventions
Antidepressant prescriptions varied between studies with three
prescribing sertraline (Bloch 2012; Hantsoo 2013; Wisner 2006),
one fluoxetine (Appleby 1997), one paroxetine (Yonkers 2008),
and one nortriptyline (Wisner 2006; used as a comparison with
sertraline). Sharp 2010 allowed choice of antidepressants based on
physician and participant preference. Although GPs were given
prescribing guidelines in this study (with SSRIs recommended as
the first-line therapy in keeping with national guidelines), there
were no set drugs for the trial. Information on the antidepressants prescribed was obtained through participant self report at all
follow-up points and by recording prescribing information from
medical notes. Most participants were prescribed citalopram, fluoxetine or sertraline; full details of the antidepressants prescribed
and the number of participants prescribed each antidepressant are
given in the Characteristics of included studies table.
One study (Hantsoo 2013) had a one-week run-in period to the
trial during which all participants took placebo only, followed by
participants in the antidepressant group being given sertraline 50
mg per day. In the other two trials prescribing sertraline, both
Bloch 2012 and Wisner 2006 had initial doses of 25 mg per day,
increasing to 50 mg after two (Wisner 2006) or seven days (Bloch
2012) . In Hantsoo 2013 and Wisner 2006, the maximum dose
allowed was 200 mg per day, in Bloch 2012, it was 100 mg per
day. Participants randomised to nortriptyline in the Wisner 2006
study started on 10 mg per day, increasing to 25 mg per day up
to a maximum of 150 mg per day. The prescription of paroxetine
in the Yonkers 2008 study began with 10 mg per day, increasing
to a maximum of 40 mg per day. Initial dosage of antidepressants
were described as increasing at regular intervals in all of the trials
except Appleby 1997 (where no data on prescribing patterns were
given), as guided by tolerability of treatment and effect on symptoms. Where specified, dosage was once daily. Data on dosage was
collected in Sharp 2010, but is not reported here owing to the
heterogeneity of treatments given. Adherence was monitored with
pill counts in two trials (Bloch 2012; Yonkers 2008), self report
plus review of prescription data in one trial (Sharp 2010), and
serum drug level monitoring in one trial (Wisner 2006).
Four studies had a placebo control with study personnel and participants blinded to group allocation (Appleby 1997; Bloch 2012;
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Hantsoo 2013; Yonkers 2008). Bloch 2012 and Appleby 1997
also included psychological therapy in both the placebo and the
active treatment arms (brief dynamic psychotherapy (Bloch 2012)
and CBT-based counselling (Appleby 1997)). In Appleby 1997,
participants were randomly assigned to receive either one or six
sessions of the CBT-based counselling. Wisner 2006 compared
the efficacy of two pharmacological treatments (nortriptyline and
sertraline) in a two-arm blinded RCT. Sharp 2010 conducted an
unblinded pragmatic RCT in which participants were randomised
to antidepressants or four weeks of treatment as usual followed
by listening visits. Antidepressants were prescribed by the participant’s GP, who was requested to provide no other counselling
or psychological intervention for women in this arm of the trial.
However, the participants receiving antidepressants also received
usual care and had several GP appointments for antidepressant
monitoring. The comparison group received treatment as usual
(general supportive care from GPs) for the first four weeks to allow
the effectiveness of antidepressants to be compared with treatment
as usual and to replicate the waiting period that would likely occur
prior to a woman beginning counselling for postnatal depression.
The GPs were requested not to prescribe antidepressants or additional psychological interventions unless clinically necessarily. The
listening visits (non-directive counselling) began after this fourweek period and were delivered by trained health visitors (up to
eight sessions). The primary aim of this study was to evaluate the
clinical effectiveness of antidepressants for mothers with postnatal depression compared with treatment as usual (i.e. outcomes at
four weeks prior to the commencement of listening visits). The
secondary aim of this study was to compare outcomes in the two
groups at 18 weeks (i.e. women randomised to antidepressants
compared with women randomised to listening visits following
treatment as usual). In this trial, women were also able to change
to (or add in) the alternative intervention (i.e. antidepressants or
listening visits) at any point after four weeks.
Follow-up intervals ranged from seven weeks (Hantsoo 2013) to
24 weeks (Wisner 2006; main outcomes as eight weeks followed
by a 16-week continuation phase). In the study by Hantsoo 2013,
follow-up at seven weeks included the one-week run-in placebo
period; therefore, outcomes after six weeks of active treatment
versus placebo were assessed. One study followed up participants
at four and 18 weeks (with the four-week follow-up comparing
antidepressants with treatment as usual, and the 18-week followup comparing antidepressants with listening visits) (Sharp 2010).
In another study, outcome assessments took place at eight weeks
(Yonkers 2008). Appleby 1997 and Bloch 2012 had a 12-week
follow-up period. In the final four weeks of the Bloch 2012 trial
(after the main outcomes at eight weeks), the trial was converted
to an open trial for the continuation phase.
Outcomes
Primary outcome assessment
The primary outcome in this review was a dichotomous measure
of depression response or remission, which was assessed in five of
the six included studies (data on response and remission were not
available from Appleby 1997). This was defined in the following
ways:
• Bloch 2012: response: greater than 50% reduction in
MADRS or EPDS score during treatment; remission: final score
less than 10 on the MADRS scale or less than 7 on the EPDS
(outcomes at eight weeks);
• Sharp 2010: remission (termed ’improvement’ in the
original trial): less than 13 on the EPDS (outcomes at four and
18 weeks);
• Wisner 2006: response: 50% reduction in HAM-D from
baseline; remission: less than 7 on the HAM-D (outcomes at
eight weeks);
• Yonkers 2008: response: CGI scale score of 1 or 2;
remission: HAM-D score 8 or less (outcomes at eight weeks);
• Hantsoo 2013: response: 10 or less on HAM-D plus at least
50% decrease in HAM-D score from baseline plus CGI
(improvement scale) 2 or less; remission: as ’response’ plus
HAM-D score less than 7 (outcomes after six weeks of treatment
(study week seven, including the one-week run-in period)).
Further details on these scales are given in the Characteristics of
included studies tables.
Adverse effects
In two studies, specific side effect rating scales were used (Asberg
Side Effects Rating Scale (Wisner 2006), and the UKU Side Effect Rating Scale (Bloch 2012)). Other trials reported adverse outcomes but the method of the assessment was not specified.
Secondary outcomes
Secondary outcomes were severity of depression, acceptability,
cognitive development of the infant, maternal satisfaction, maternal relationship with the baby, social functioning, establishment
or continuation of breastfeeding, neglect or abuse of the baby, effect on marital or family relationships and quality of life, although
there were no data from the included studies for several of the
outcomes.
Excluded studies
We excluded studies for the following reasons: antidepressant treatment not randomised (two studies: Rojas 2007; Suri 2005), same
antidepressants given in both arms (three studies: Misri 2004;
Yu 2006; Zhao 2006), no antidepressant treatment (one study:
Bennett 2001) and ineligible study population (Stein 2012). See
Characteristics of excluded studies for further details.
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Ongoing studies
New studies found at this update
We identified one ongoing RCT comparing sertraline with interpersonal psychotherapy and with placebo (NCT00602355). Based
on the limited available information, we believe that this study
will be eligible for inclusion when completed (see Characteristics
of ongoing studies).
We included five new studies in this update (Bloch 2012; Hantsoo
2013; Sharp 2010; Wisner 2006; Yonkers 2008).
Studies awaiting classification
We identified two RCTs awaiting classification: one comparing sertraline with transdermal oestradiol and with placebo
(NCT00744328) and one comparing sertraline with CBT and
with combined therapy (sertraline and CBT) (NCT02122393).
From the available evidence it appears that both studies would
be eligible for the review, but no data is currently available for
either study (see Characteristics of studies awaiting classification
for more details).
Risk of bias in included studies
We used the Cochrane ’Risk of bias’ assessment tool to evaluate
each study in five domains of potential bias (Higgins 2011): random sequence generation, allocation concealment, blinding, incomplete outcome data and selective outcome reporting. We also
assessed adherence to medication as an additional potential source
of bias.
See Characteristics of included studies table for full details of risk
of bias judgements for each study. Graphical representations of the
overall risk of bias in included studies are presented in Figure 2
and Figure 3.
Figure 2. Risk of bias graph: review authors’ judgements about each risk of bias item presented as
percentages across all included studies.
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Figure 3. Risk of bias summary: review authors’ judgements about each risk of bias item for each included
study.
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19
Allocation
performed the outcome assessments in the Bloch 2012 study so
the risk of bias for blinding of outcome assessment was unclear.
Sequence generation
Five of the six included studies described methods of random
sequence generation with low risk of bias (e.g. using computeror pharmacy-generated random numbers). For one study, the risk
of bias in this domain was unclear; the study was described as
randomised but there were insufficient details to assess whether
appropriate methods of randomisation were used (Hantsoo 2013).
Allocation concealment
Only one included study gave sufficient information on allocation
concealment to ensure low risk of bias in this domain (a remote
computerised randomisation service was used and the methods of
sequence generation were concealed from those involved in the
enrolment and randomisation of participants) (Sharp 2010). None
of the other studies provided details on allocation concealment.
Blinding
Blinding of participants and personnel
Four studies had low risk of bias with study personnel and participants blinded to treatment allocation. One study compared
the antidepressant intervention with listening visits so blinding
of study personnel and participants was not possible, leading to
high risk of bias in this domain (Sharp 2010). The risk of bias
was unclear in Bloch 2012. Participants and the managing psychiatrist were blinded to treatment condition, but when the blind
was assessed at the end of the study the psychiatrist guessed group
assignment incorrectly in every case. This suggests that there may
have been some differences between the intervention groups; incorrect assignment of every participant when there are only two
treatment options implies that the psychiatrist correctly grouped
the participants with others who had received the same treatment,
although incorrectly guessed treatment status of these groups. It
should be noted that only Bloch 2012 reported assessment of the
success of blinding, although Hantsoo 2013 described the withdrawal of one participant following accidental unblinding in the
penultimate week of the study.
Blinding of outcome assessment
Four studies had low risk of bias with outcome assessors blinded to
treatment allocation. Sharp 2010 did not blind outcome assessors,
leading to high risk of bias. No details were provided on who
Incomplete outcome data
The greatest risk of bias in the studies included in this review
came from incomplete outcome data (attrition bias), with only one
study having low risk of bias in this domain (Bloch 2012). Yonkers
2008 had very high risk of attrition bias, with 39 women withdrawing from the study out of the 70 women randomised (56%).
This means that the study findings must be interpreted extremely
cautiously. However, dropout reasons and numbers were similar
between treatment groups and sensitivity analyses assuming that
all drop-outs had either positive or negative outcomes in the trial
found that antidepressants remained associated with significantly
higher remission rates than placebo in both scenarios. This suggests that the primary finding was robust to a range of outcomes
for drop-outs.
Wisner 2006 had high risk of bias from incomplete outcome data.
Significantly more participants withdrew from the sertraline than
the nortriptyline group in the first eight weeks of the study and
there was high attrition from both groups (withdrawal rates: 23/
55 (42%) with sertraline and 13/54 (24%) with nortriptyline;
Wilcoxon P value = 0.02). Reasons for withdrawal were assessed
and although “side effects” and “clinical deterioration” did not
differ in frequency between the two groups, significantly more
women in the sertraline group withdrew by personal choice or
were lost to follow-up without reasons given, which may reflect
factors associated with clinical outcomes or side effects.
In four studies, there was some evidence of potential risk of bias,
but we rated this as ’unclear’ owing to insufficient details in reporting. In Appleby 1997, 26 of the 87 women dropped out over
the course of the study, although with relatively similar rates across
treatment groups. Timing and reasons for drop-out were reported
but in many cases this was “no reason given”, meaning that it
is difficult to assess whether reasons for drop-out varied between
groups. In Hantsoo 2013, seven of the 36 women dropped out
over the course of the trial. Again, there were similar numbers
of drop-outs in the two treatment groups but all women dropping out due to clinical deterioration had received the placebo,
which may have led to an underestimation of the intervention
effect. Sharp 2010 reported some differential drop-out between
the antidepressant group and the treatment as usual followed by
listening visit group (higher in the antidepressant group), which
was not statistically significant at four weeks (antidepressant group
18% drop-out, 23 women; treatment as usual group 10% dropout, 13 women; P value = 0.09) but was significant at 18 weeks
(antidepressant group 25% drop-out, 32 women; listening visits
13% drop-out, 16 women; P value = 0.015). However, sensitiv-
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ity analyses examining the impact of attrition (including multiple imputation) found that study findings were robust to a range
of outcomes for study drop-outs. Sharp 2010 did not give characteristics of the drop-outs separately by intervention group and
reasons for withdrawal were not described so it is not possible to
assess whether these differ between groups.
All studies used LOCF in cases of missing data, except for Sharp
2010 who used multiple imputation. All studies conducted ITT
analyses for their primary outcomes and all results for the primary
outcome of this review are reported using ITT, although some
secondary analyses were reported using complete case analysis only
(and are indicated as such).
Selective reporting
Bias from selective outcome reporting was unclear in four of the
studies: in most studies, the protocols were unavailable and, in one
study, the protocol had insufficient detail on outcomes to assess
selective reporting (Bloch 2012). In Sharp 2010, the protocol was
available and all pre-specified primary outcomes were reported, but
outcomes from assessments of participants’ partners, the HOME
measure and Bayley Scale of Infant Development were not reported. Authors stated that these outcomes would be reported in a
subsequent paper but we could not find this. In Yonkers 2008, the
Social Adjustment Scale and SF-36 were included in the methods
but not reported in the results. We believe that the general absence of data on child outcomes and breastfeeding safety in the six
studies reflects the fact that these data were not collected, rather
than selective outcome reporting; however, this cannot be assessed
without access to the study protocols.
Other potential sources of bias
Adherence to antidepressants is often low, which could bias study
findings, so we assessed risk of bias related to low adherence in the
included studies. Wisner 2006 assessed serum levels as a measure
of compliance and found that 14 women (out of 95 study participants) had minimal levels of the antidepressant in their blood, despite claiming compliance. These women were evenly distributed
between the two antidepressant groups and results did not alter when these women were removed from analysis. Therefore,
the risk of bias related to adherence in this study was low. Sharp
2010 collected self reported data on adherence to medication and
had high risk of bias in this area; only 56% (59 women) of the
106 women who were randomised to antidepressant treatment
and followed up reported taking any antidepressants in the first
four weeks after randomisation. Of the women followed up at
18 weeks, 64% of participants randomised to antidepressants reported taking antidepressants in the previous four weeks (62/97),
and 34% of women randomised to listening visits reported taking
antidepressants in the previous four weeks (37/109). Two studies
provided no details of adherence to antidepressant medication so
risk of bias in these studies was unclear (Appleby 1997; Hantsoo
2013). One study stated that pill counts were used to monitor
compliance but it is unclear from the results how many women
were non-compliant (Bloch 2012). Yonkers 2008 used pill counts
to assess adherence and found that seven of the 35 women randomised to antidepressant treatment were non-compliant (took
less than 80% of pills) at one visit, four were non-compliant at two
visits and one was consistently non-compliant and consequently
removed from active treatment in the study. In the placebo group,
10 of the 35 women were non-compliant at one visit, three were
non-compliant at two or more visits and one was non-compliant
at four visits. It is unclear to what extent this may have biased
study findings, as we do not know how much medication the noncompliant women were taking (this could range between 0% and
79% based on reported data) or whether adherence was only reported for women who completed the study.
Effects of interventions
See: Summary of findings for the main comparison
All included studies reported effect on depressive symptoms as
their primary outcome. Five studies included response or remission
rates (the primary outcome for this review). The way these were
characterised for each study is listed in the Included studies section
above and the summary of findings tables. Further details on the
scales are given in the Characteristics of included studies tables.
Due to the small number of studies and heterogeneity between papers it was only possible to conduct a meta-analysis for the comparison of antidepressant vs placebo. The meta-analysis included two
studies where women were randomised to SSRIs or placebo, and
one where women were randomised to SSRIs and psychological
therapy or placebo and psychological therapy. Other findings are
discussed narratively for the following comparison groups based
on class of drug, where possible: antidepressants vs treatment as
usual, antidepressants vs psychosocial interventions; antidepressants vs other pharmacological interventions. No data were available for our planned comparison of antidepressants versus psychological interventions.
Comparison 1: antidepressants versus placebo
Selective serotonin re-uptake inhibitors versus placebo
Primary outcomes
1.1 Remission/response of depression
Four studies investigated the effect of SSRIs versus placebo
(Appleby 1997; Bloch 2012; Hantsoo 2013; Yonkers 2008). Two
studies (106 women) compared SSRIs (sertraline (Hantsoo 2013);
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21
paroxetine (Yonkers 2008)) with placebo, with both studies assessing response and remission. The other two studies (127 women)
compared SSRIs (fluoxetine (Appleby 1997); sertraline (Bloch
2012)) with placebo, with both study arms additionally receiving
psychological therapy (CBT-based counselling (Appleby 1997);
brief dynamic psychotherapy (Bloch 2012)). Of these two, only
Bloch 2012 assessed response or remission.
Random effects meta-analyses were conducted to pool data on
response and remission from the three studies with this data (146
participants). The pooled estimate showed a 43% greater chance
of responding for those randomised to SSRIs compared with those
randomised to placebo (RR 1.43, 95% CI 1.01 to 2.03; Analysis
1.1, Figure 4). There was no evidence of meaningful heterogeneity
in this meta-analysis: I2 was 0%, the chi2 test for heterogeneity
was not significant and the confidence intervals from individual
studies overlapped. The pooled estimate for remission found a
79% greater chance of remission for those randomised to SSRIs
compared with those randomised to placebo (RR 1.79, 95% CI
1.08 to 2.98; Analysis 1.2, Figure 5). Again, heterogeneity was
found to be low: I2 was 23%, the chi2 test was not significant and
confidence intervals from individual studies overlapped.
Figure 4. Forest plot of comparison: 1 Selective serotonin re-uptake inhibitors versus placebo, outcome: 1.1
Response rate at post-treatment.
Figure 5. Forest plot of comparison: 1 Selective serotonin re-uptake inhibitors versus placebo, outcome: 1.2
Remission rate at post-treatment.
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1.2 Adverse effects
All studies comparing SSRI versus placebo examined side effects,
with none describing a significant difference between groups (
Appleby 1997; Bloch 2012; Hantsoo 2013; Yonkers 2008).
Participants in the Yonkers 2008 trial reported decreased appetite (antidepressant group 3/35 women, 9%; placebo group 2/35
women, 6%), diarrhoea (antidepressant group 4/35, 11%; placebo
group 4/35, 11%), dizziness (antidepressant group 6/35, 17%;
placebo group 3/35, 9%), dry mouth (antidepressant group 4/
35, 11%; placebo group 0/35), headache (antidepressant group
9/35, 26%; placebo group 13/35, 37%), nausea (antidepressant
group 5/35, 14%; placebo group 6/35, 17%), somnolence and
drowsiness (antidepressant group 5/35, 14%; placebo group 5/35,
14%). Although some side effects appeared more common in the
antidepressant group (e.g. dizziness, dry mouth), no significant
differences were found in symptoms experienced by participants
in the paroxetine as compared with the placebo group (P values
ranging from 0.11 to greater than 0.99). The overall proportion
of women experiencing side effects was not reported.
In Hantsoo 2013, 3/17 women from the sertraline group reported side effects: nausea (3/17 women; 17.6%), headache (1/
17 women; 5.8%) and diarrhoea (1/17 women; 5.8%). Frequent
diarrhoea was reported by one participant in the placebo group
(1/19; 5.3%). No participants dropped out due to side effects and
no adverse events were reported for any of the participants or their
breastfeeding infants (number breastfeeding: 6/17 in the sertraline
group, 5/19 in the placebo group).
Bloch 2012 reported a hypomanic switch in two women from the
brief dynamic psychotherapy plus sertraline group at week eight
(one woman on sertraline 50 mg and one woman on sertraline 100
mg). UKU Side Effect Rating scores showed no significant difference between treatment groups at week eight (P value = 0.456),
or at 12 weeks (P value = 0.937), although the overall proportion
of women experiencing side effects in each group was not given,
neither were the details of types of side effects experienced.
In the Appleby 1997 study, one woman dropped out of the fluoxetine group and three women dropped out of the placebo group due
to side effects, but the nature of these side effects was not reported.
Side effects were only reported among women who dropped out
of the study.
Secondary outcomes
1.3 Severity of depression
In the trial by Yonkers 2008, change in severity of depression was
assessed as the difference in mean score on repeated measures of
the HAM-D, Inventory of Depressive Symptomatology, Self Report (IDS-SR), and CGI-S (Clinical Global Impressions, Severity
of Illness scale) between the antidepressant and placebo groups.
There was no significant difference between groups on the HAMD (-1.62; P value = 0.22).There was a significant main effect of
group on the IDS-SR scores (-4.98; P value = 0.019); however,
IDS-SR scores were significantly different between the antidepressant and placebo groups at baseline and the authors concluded that
it was this baseline difference carried over at later time points as the
group by time interaction effect was not significant. The authors
concluded that there was significantly greater improvement in the
antidepressant than placebo group based on CGI-S scores (main
effect -0.48; P value = 0.047, groups did not differ at baseline).
In the trial by Hantsoo 2013, severity of depression was defined as
a treatment group by time interaction with the baseline score as a
covariate on the HAM-D and EPDS. Analysis of change in scores
over time in the ITT group showed that there was not a significant
group by time effect for the HAM-D (F(1,145) = 2.05; P value =
0.15) or EPDS (F(1,137) = 0.43; P value = 0.51).
In the study by Bloch 2012, ITT analyses using LOCF indicated
no group by time interaction effect for depression scores on either
the MADRS (F[4,35] = 0.97; P value = 0.44) or EPDS (F[4,35]
= 0.62; P value = 0.65) across the eight-week intervention period.
Appleby 1997 assessed reduction in depression using the CIS-R,
HAM-D and EPDS, with ITT analysis (LOCF). The geometric
mean scores at 12 weeks on the CIS-R were 11.1 (95% CI 6.9
to 17.6) for fluoxetine plus one session of counselling and 19.1
(95% CI 15.4 to 23.5) for placebo plus one session of counselling.
Geometric mean scores at 12 weeks on the CIS-R were 10.5 (95%
CI 6.6 to 16.6) for fluoxetine plus six sessions and 13.0 (95%
CI 9.2 to 18.1) for placebo plus six sessions of counselling. The
calculated percentage difference in geometric mean scores between
fluoxetine and placebo at 12 weeks was 40.7% (95% CI 10.9% to
60.6%). Similar findings were observed using the HAM-D with
the following geometric mean scores reported at 12 weeks: 4.4
(95% CI 2.4 to 7.4) for fluoxetine plus one session of counselling
and 8.1 (95% CI 6.1 to 10.7) for placebo plus one session of
counselling; 5.1 (95% CI 2.6 to 9.2) for fluoxetine plus six sessions
of counselling and 4.9 (95% CI 3.0 to 8.9) for placebo plus six
sessions of counselling. Finally, the geometric mean scores on the
EPDS at 12 weeks were reported as follows: 7.1 (95% CI 5.0 to
10.1) for fluoxetine plus one session of counselling and 10.3 (95%
CI 8.1 to 13.2) for placebo plus one session of counselling; 7.5
(95% CI 4.6 to 11.8) for fluoxetine plus six sessions of counselling
and 9.5 (95% CI 7.2 to 12.5) for placebo plus six sessions of
counselling. Authors of this study concluded that fluoxetine was
significantly more effective than placebo and, after an initial session
of counselling, was as effective as a full course of CBT counselling
in the treatment of postnatal depression. However, the 95% CIs
of geometric mean scores for all treatment groups overlap.
1.4 Acceptability
While no direct assessments of treatment acceptability were made,
treatment adherence and withdrawal rate may be indicative of the
level of treatment acceptability. In the paroxetine arm of Yonkers
2008, one woman withdrew due to nausea, six due to lack of efficacy, five who felt well and no longer desired treatment, one who
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became pregnant and one who was not adherent to medication.
A further six women were lost to follow-up. Among the women
on placebo, four left due to perceived adverse effects, seven discontinued due to lack of efficacy, two felt better and no longer
desired treatment and one moved out of the area. A further nine
women in this arm were lost to follow-up. In terms of treatment
compliance, among the women on paroxetine, seven were taking
less than 80% of medication at one visit, four were non-adherent
on a second visit and one was excluded from the trial for ongoing non-adherence. Among the women on placebo, 10 were noncompliant at one visit, three were non-compliant at two visits and
one was non-compliant on a fourth visit.
In the trial comparing sertraline and placebo, Hantsoo 2013 reported that 36/36 (100%) women remained in the trial at week
two, 33/36 (92%) completed through week four and 29/36 (81%)
completed through week seven. Three of 19 women on placebo
left the trial due to clinical worsening. Among the women randomised to antidepressants, 3/17 (17.6%) dropped out (e.g. due
to death in the family or unable to contact) and 1/17 (5.9%) was
excluded after the blind was broken due to an administrative error.
The authors did not report on adherence to medication is either
treatment arm.
Appleby 1997 reported a similar dropout rate in all treatment
arms. Fourteen of 43 (32.6%) women on fluoxetine dropped out
of the trial. Of these, two reported that they ’disliked the drug’,
three reported a lack of improvement, one reported side effects
(type not specified) and eight gave no reason for dropping out.
Twelve of 44 (27.3%) women taking placebo dropped out of the
trial, of whom three disliked the drug, three reported side effects
(type not specified) and six gave no reason.
Bloch 2012 reported that seven women (3/20 from the placebo
group and 4/20 from the antidepressant group) discontinued
the trial between week four and week eight, at which point primary outcomes were reported. Among drop-outs from the placebo
group, two reported lack of motivation as their reason for dropout and one reported clinical deterioration; among drop-outs from
the antidepressant group, two reported lack of motivation as their
reason for drop-out and two reported clinical deterioration). No
details on adherence to medications in either treatment arm were
provided by either Appleby 1997 or Bloch 2012.
1.5 Cognitive development of the infant
No data available.
1.9 Establishment or continuation of breastfeeding
No data available.
1.10 Neglect or abuse of the baby
No data available.
1.11 Effect on marital and family relationships
No data available.
1.12 Quality of life
No data available.
Comparison 2: antidepressants versus treatment as
usual
Primary outcomes
2.1 Remission/response of depression
One study (254 women) compared antidepressants with treatment
as usual (outcomes assessed after four weeks) (Sharp 2010). There
were no set antidepressants (prescriptions based on GP/participant
choice) although most participants were prescribed citalopram,
fluoxetine or sertraline (see Characteristics of included studies table for details). Results showed higher remission (EPDS less than
13) for women in the antidepressant group compared with treatment as usual after four weeks (improvement: 37.2% (48/129)
women with antidepressant group versus 17.6% (22/125) women
with treatment as usual). The RR was significant (RR 2.11, 95%
CI 1.36 to 3.28; Analysis 2.1). This RR was based on the assumption that all the women who were lost to follow-up did not have
remission of depression (calculated for this review on a ’once-randomised always-analyse’ basis). In the Sharp 2010 study, multiple imputation was also used to impute missing data and ORs
calculated. At four weeks, the imputed OR for remission in the
antidepressant group compared with treatment as usual was 3.2
(95% CI 1.7 to 6.1).
2.2 Adverse effects
No adverse events or serious side effects of treatment were reported
in the Sharp 2010 trial. No data were reported on adverse effects
related to infants or the safety of breastfeeding.
1.6 Maternal satisfaction
No data available.
Secondary outcomes
1.7 Maternal relationship with the baby
2.3 Severity of depression
No data available.
When outcomes were assessed in terms of continuous measurement of EPDS (for those followed up only; adjusted for baseline
EPDS score and centre), this resulted in a two-point difference in
means in favour of the antidepressant group when compared with
1.8 Social functioning
No data available.
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treatment as usual at four weeks (MD -2.1, 95% CI -3.3 to -0.9;
P value < 0.001).
2.4 Acceptability
In the Sharp 2010 trial, more women in the antidepressant group
withdrew or were lost to follow-up than women randomised to
treatment as usual (withdrawal at four weeks: antidepressant group
23/129 (17.8%), treatment as usual group 13/125 (10.4%); P
value = 0.090). From the reported data, it was not possible to determine whether this difference in withdrawal was due to a lack of
acceptability of treatment with antidepressants or to other factors.
Adherence was assessed in this trial using the Morisky Adherence
Scale and four items adapted from a scale reported by Schroeder
2006. Authors reported low adherence to treatment: the percentage of women randomised to antidepressants who reported actually taking antidepressants in the previous four weeks was 56% at
four weeks (59/106; only reported for the women followed up).
found a significant difference in favour of antidepressants on the
SF-12 Mental Health component at four weeks (MD 0.36, 95%
CI 0.14 to 0.57; P value = 0.001) but no difference on the SF-12
physical component score (MD -0.002, 95% CI -0.24 to 0.23;
P value = 0.98). The EQ-5D utility score showed marginal, nonsignificant evidence in favour of the antidepressant group at four
weeks with a reported adjusted MD of 0.05 (95% CI -0.002 to
0.11; P value = 0.059) and using the EQ-5D visual analogue scale
there was no significant difference (MD 3.5, 95% CI -1.8 to 8.8;
P value = 0.20).
Comparison 3: antidepressants versus psychosocial
interventions
Antidepressants versus listening visits
2.5 Cognitive development of the infant
No data available.
2.6 Maternal satisfaction
No data available.
2.7 Maternal relationship with the baby
Sharp 2010 examined the effect on maternal functioning using the
Maternal Adjustment and Maternal Attitudes (MAMA) Attitudes
Towards Pregnancy and Baby subscale (postpartum version). The
study found weak evidence of benefit to the antidepressant group
compared with treatment as usual at four weeks (adjusted MD
1.1, 95% CI -0.02 to 2.2 P value = 0.05).
2.8 Social functioning
No data available.
Primary outcomes
3.1 Remission/response of depression
Sharp 2010 compared antidepressants with listening visits at the
18-week outcome assessment. Antidepressants were not significantly more effective than listening visits, with remission of depression (EPDS less than 13) occurring in 46.5% (60/129) of
women randomised to antidepressants compared with 44.8% (56/
125) of women randomised to listening visits (RR 1.04, 95% CI
0.79 to 1.36; see Analysis 3.1). Sharp 2010 also performed multiple imputation to address missing data and calculated an OR
for remission of depression at 18 weeks, which was not significant
(OR 1.4, 95% CI 0.8 to 2.4).
3.2 Adverse effects
Sharp 2010 reported no adverse events or serious side effects of
treatment at 18 weeks.
2.9 Establishment or continuation of breastfeeding
No data available.
Secondary outcomes
2.10 Neglect or abuse of the baby
No data available.
2.11 Effect on marital and family relationships
Sharp 2010 examined the effect of treatment on marital relationships using the Golombok Rust Inventory of Marital State
(GRIMS) scale. There was no evidence of any difference in marital
relationship between treatment groups (4 weeks: -0.6, 95% CI 1.9 to 0.7; P value = 0.39).
2.12 Quality of life
Sharp 2010 investigated the effect of treatment with antidepressants compared with treatment as usual on health-related quality
of life, measured with the 12-item Short Form (SF-12) Mental
Health and Physical Health components and the EQ-5D. They
3.3 Severity of depression
When antidepressants and listening visits were compared at 18
weeks in Sharp 2010 (for those followed-up only), there was no
evidence of a significant difference between the groups in severity
of depression (MD in EPDS scores: -0.7, 95% C.I -2.1 to 0.8; P
value = 0.37).
3.4 Acceptability
Significantly more women withdrew or were lost to follow-up in
the antidepressant group (32/129 (24.8%)) than the listening visits group (16/125 (12.8%)) (P value = 0.015). In terms of adherence at 18 weeks, 64% of women randomised to antidepressants
reported taking antidepressants in the previous four weeks (62/97
women followed up) and 34% of women randomised to listening
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visits reported taking antidepressants in the past four weeks (37/
109 followed up).
3.5 Cognitive development of the infant
No data available.
3.6 Maternal satisfaction
No data available.
3.7 Maternal relationship with the baby
There was no difference in maternal functioning between the antidepressant and listening visits groups at 18 weeks in Sharp 2010
(adjusted differences 1.0, 95% CI -0.3 to 2.2; P value = 0.14),
assessed using the MAMA Attitudes Towards Pregnancy and Baby
subscale (postpartum version).
3.8 Social functioning
No data available.
3.9 Establishment or continuation of breastfeeding
No data available.
3.10 Neglect or abuse of the baby
No data available.
3.11 Effect on marital and family relationships
There was no evidence of any difference between the antidepressant and listening visits group for marital relationships (assessed
using the GRIMS scale; -1.2 (95% CI -2.8 to 0.4; P value = 0.14)
in Sharp 2010.
3.12 Quality of life
At 18 weeks, Sharp 2010 compared antidepressants with listening
visits and found no difference on the SF-12 Mental Health component score (MD 0.09, 95% CI -0.19 to 0.37; P value = 0.53)
or Physical Health component score (MD 0.12, 95% CI -0.12 to
0.36; P value = 0.34). No significant differences were identified
on the EQ-5D utility score (adjusted difference -0.01, 95% CI 0.08 to 0.05; P value = 0.68) or on the EQ-5D visual analogue
scale (MD -1.6, 95% CI -8.1 to 4.9; P value = 0.63).
One study (109 women) compared an SSRI (sertraline) with a
TCA (nortriptyline) and found no significant difference in effectiveness for treating postnatal depression, with primary outcome
measures at week eight of treatment (Wisner 2006).
No differences between drug groups were observed using ITT
analysis of the proportion of women who responded (50% reduction in HAM-D from baseline to week eight), 56% (31/55) of
women randomised to sertraline and 69% (37/54) of women randomised to nortriptyline (RR 0.82, 95% CI 0.61 to 1.10; Analysis
4.1). There was also no difference in the proportion of women
who remitted (HAM-D less than 7 at week eight): 46% (25/55) of
women randomised to sertraline and 48% (26/54) of women randomised to nortriptyline (RR 0.94, 95% CI 0.63 to 1.41; Analysis
4.2).
4.2 Adverse effects
In the Wisner 2006 study, there was no difference between sertraline and nortriptyline in the overall number of side effects reported (using the Asberg Side Effects Rating Scale; Chi2 1 = 0.00;
P value = 1.00). However, some side effects were more common
among women who took nortriptyline than women taking sertraline: cholinergic symptoms such as moderate to severe thirst
(after week three: 19% to 23% with nortriptyline versus 3% to
4% with sertraline; P value = 0.02), dry mouth (20% to 40% with
nortriptyline versus 2% to 11% with sertraline for weeks two to
eight; P value = 0.001) and constipation (23% to 25% with nortriptyline versus 7% to 12% with sertraline; P value = 0.05). Other
side effects were more common in the sertraline than nortriptyline
group: constant or severe headaches (10% to 15% with sertraline
versus 1% to 2% with nortriptyline; P value = 0.05 at weeks two
and three), slight to moderate increased perspiration (35% to 40%
with sertraline versus 15% to 20% with nortriptyline for weeks
one to three; P value = 0.04) and hot flushes interrupting sleep
(4% to 10% with sertraline versus 0% to 2% with nortriptyline
for weeks one to three; P value = 0.04).
Wisner 2006 reported that babies of breastfeeding mothers in the
trial had no adverse effects.
Secondary outcomes
4.3 Severity of depression
Comparison 4: antidepressants versus other
pharmacological interventions
Selective serotonin re-uptake inhibitors versus
tricyclic antidepressants
For the 83 women providing a minimum of three weeks’ follow-up
data, there was no difference between drug groups for depression
symptoms at four and eight weeks or across eight to 24 weeks (Chi
2 = 0.08; P value = 0.77). The interaction of time by drug group
1
on depressive symptoms was also not significant (Chi2 8 = 3.64; P
value = 0.89).
Primary outcomes
4.4 Acceptability
4.1 Remission/response of depression
Significantly more women randomised to sertraline than women
randomised to nortriptyline withdrew from the study in the first
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26
eight weeks (23/55 (42%) with sertraline versus 13/54 (24%)
with nortriptyline; Wilcoxon; P value = 0.02), with a significantly
higher proportion of women lost to follow-up or withdrawing by
personal choice in the sertraline group (20% with sertraline versus
6% with nortriptyline; Wilcoxon Chi2 1 = 4.86; P value = 0.03).
The proportion of women withdrawing for other reasons (side
effects, hypomania occurrence or clinical deterioration) did not
differ significantly between the two drug groups. There were no
significant differences in rates of withdrawal after week eight (entering the continuation phase of the trial). Of those eligible to enter the continuation phase, 24/32 (75%) of those randomised to
sertraline and 25/40 (63%) of those randomised to nortriptyline
chose to do so (Chi2 1 = 1.28; P value = 0.26). Adherence (assessed
through serum levels) found that 14 women had minimal drug
levels in their blood despite claims of compliance. There was no
significant difference found in lack of compliance between women
assigned to nortriptyline (9/51, 18%) and women assigned to sertraline (5/44, 11%; Fisher exact test; P value = 0.29).
4.5 Cognitive development of the infant
No data available.
4.6 Maternal satisfaction
No data available.
4.7 Maternal relationship with the baby
No data available.
4.8 Social functioning
Wisner 2006 investigated the effect of treatment with nortriptyline versus sertraline on social functioning as assessed by the Social Problems Questionnaire. No significant effect of treatment
modality was found at week eight (change in log-likelihood Chi
2
1 = 0.25; P value = 0.62) or when the interaction of time by drug
group was examined (change in log-likelihood Chi2 2 = 2.22; P
value = 0.33). There were also no significant differences between
antidepressant groups at week 24.
4.9 Establishment or continuation of breastfeeding
No data available.
Subgroup analyses
We were unable to conduct subgroup analyses due to the small
number of studies included in the meta-analysis for the SSRIs
versus placebo comparison and the lack of data for other metaanalyses.
Sensitivity analyses
Comparison: selective serotonin reuptake inhibitors versus
placebo
Sensitivity analyses were conducted to examine the effect of removing studies with combined treatment (i.e. Bloch 2012 in which
all participants received brief dynamic psychotherapy as well as
sertraline or placebo). After removing Bloch 2012 the pooled risk
ratio for response was 1.62 (95% CI 0.98 to 2.67; Analysis 5.1)
and the pooled risk ratio for remission was 2.56 (95% CI 1.31 to
5.00; Analysis 5.2). In both cases this reflects an increase in risk
ratios (from RR 1.43 for response and RR 1.79 for remission in
the main analyses); however confidence intervals also increased as
the pooled estimates were now based on just two studies and only
the effect on remission remained statistically signficant.
Additional sensitivity analyses were conducted to examine the effects of removing studies with high dropout or high risk of bias in
any domain; both of these required Yonkers 2008 to be removed
from the pooled estimates. After removing Yonkers 2008 from the
analyses, the pooled risk ratio for response was 1.52 (95% CI 0.89
to 2.58; Analysis 6.1) and the pooled risk ratio for remission was
1.60 (95% CI 0.86 to 2.97; Analysis 6.2). The effect size for response in this sensitivity analyses was slightly larger than in the
main analyses (from RR 1.43 to RR 1.52), but the effect size for
remission was reduced (from RR 1.79 to RR 1.60). Again, these
pooled estimates were now based on two studies only so confidence
intervals were extremely wide and neither effect was statistically
signficant.
Reporting bias
We were unable to assess reporting bias due to the small number of
studies included in the meta-analysis for the SSRIs versus placebo
comparison and the lack of data for other meta-analyses.
4.10 Neglect or abuse of the baby
No data available.
4.11 Effect on marital and family relationships
No data available.
4.12 Quality of life
No data available.
DISCUSSION
Summary of main results
We identified six RCTs (596 women) examining the effectiveness
of antidepressants (predominantly SSRIs: sertraline, paroxetine or
fluoxetine, and a TCA: nortriptyline) for postnatal depression.
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Four studies comparing SSRIs with placebo were identified; in two
of these trials all participants also received psychological therapy.
Meta-analyses of the three studies (146 participants) for this comparison with relevant data found that participants randomised to
SSRIs were significantly more likely to show response or remission
of depression at follow-up compared with participants randomised
to placebo. However, these findings must be interpreted with caution; the quality of evidence was graded as ’very low’ owing the
small number of included studies, high risk of bias in some trials
(including over 50% drop-out in one study) and the pooling of
results from one study which provided psychological therapy in
both the SSRI or placebo arms (Bloch 2012) with two studies that
compared SSRIs and placebo only (see Summary of findings for
the main comparison).
It was not possible to conduct meta-analyses for the other comparisons and there is insufficient evidence to conclude whether,
and for whom, antidepressant or psychosocial treatments are more
effective, or whether some antidepressants are more effective or
better tolerated than others. One study showed a significant benefit of antidepressants compared with treatment as usual (Table
1), but there was no evidence of a benefit of antidepressants compared with listening visits after these had been introduced at later
follow-up (see Table 2). No difference in effectiveness was demonstrated in the one study comparing sertraline with nortriptyline
(see Table 3), although a significantly higher proportion of women
randomised to sertraline withdrew in the first eight weeks of the
study compared with those randomised to nortriptyline which
may suggest a difference in the acceptability of the treatments.
The current evidence on antidepressant treatment of postnatal depression is limited by the small number of RCTs, underpowered
samples, lack of long-term follow-up or child outcomes and other
study limitations such as risk of bias. There were few data on
the safety of breastfeeding, adverse effects for the infants or longterm outcomes for the mother and child. Two studies reported
that there were no adverse effects for breastfed infants (Hantsoo
2013; Wisner 2006), but this was based on small numbers (e.g. six
mothers randomised to sertraline were breastfeeding in Hantsoo
2013) and limited assessment.
Side effects were reported by a substantial proportion of women
and were mainly characteristic of the type of antidepressant used
with nausea, diarrhoea and headaches reported with SSRIs and
constipation with nortriptyline. It was often difficult to interpret the severity of side effects and several studies were limited in
their assessment and reporting of side effects and adverse events;
Appleby 1997 only reported adverse events in reasons for withdrawal so we do not know whether there were side effects among
women who remained in trial and Sharp 2010 reported only ’serious side effects’ (of which there were none). High attrition rates
with limited reporting of reasons for withdrawal and the overall
lack of child outcomes make it difficult to draw conclusions about
adverse outcomes in the included studies, particularly any adverse
outcomes related to breastfed infants. It was also difficult to make
any conclusions on most of secondary outcomes, as very few of
these were addressed in any included studies. Although acceptability was generally not specifically assessed, high drop-out, low
adherence and low recruitment may reflect limited acceptability
of antidepressants or RCTs in the postnatal period.
Overall completeness and applicability of
evidence
This evidence base is limited by the fact that there have been
few trials of antidepressants in the postnatal period, and most
of these were underpowered to detect significant differences in
treatment effect. Data could only be pooled for the SSRI versus
placebo comparison and this meta-analysis included only three
studies. Sensitivity analyses were conducted to examine the effect
of removing Bloch 2012 (all participants received psychological
therapy as well as SSRI or placebo) or Yonkers 2008 (high drop-out
and high risk of bias) from the pooled estimates but are difficult to
interpret as each was based on two studies only and had extremely
wide confidence intervals. There were insufficient data to conduct
meta-analyses for the other comparisons so these conclusions are
drawn from individual studies.
Studies recruited women presenting with a major depressive disorder (except for Appleby 1997, which also included women with
minor depressive disorder) in the first few months postpartum.
However, many studies had restrictive inclusion criteria and excluded women with the most severe disorders, which will affect
the generalisability of findings. This is a particular limitation given
the need to establish an evidence base for the treatment of severe
depression in the postnatal period to enable informed decision
making for women who may be reluctant to take antidepressants.
For example, four studies excluded women with chronic depression (variously defined), four studies excluded women with suicidal ideation and three studies excluded women with treatmentresistant depression (usually defined as past failed trial or trials
of antidepressant treatment). Women with psychotic disorders or
drug or alcohol use were also excluded from the majority of studies. The findings of these studies may therefore not be generalisable to these women, who may be those in most need of pharmacological treatment. Chronic depression or depression with other
co-morbid mental disorders may be more resistant to treatment;
however, there is evidence from non-pregnant adults that antidepressants are more effective compared with placebo for individuals
with severe depression (Kirsch 2008). The three studies that excluded women who had previously been resistant to treatment for
depression may have biased findings, particularly as Hantsoo 2013
excluded women who had previously not responded to sertraline
from their trial comparing sertraline with placebo. One study allowed a choice of antidepressant medication with 14 different
antidepressants prescribed over the course of the study (majority
citalopram, fluoxetine, sertraline; see Characteristics of included
studies for full details) (Sharp 2010). However, as the results were
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not reported separately for each antidepressant, conclusions about
the effectiveness and safety of individual antidepressants cannot
be drawn from this study. The fact that there was choice of antidepressant in the Sharp 2010 study means that this (more pragmatic) trial addresses a slightly different question from those that
randomised participants to a particular antidepressant. It should
also be noted that the antidepressant groups in all studies received
usual care alongside their prescriptions, including appointments
with the study doctors (to monitor prescriptions). This needs to
be taken into account when interpreting findings, particularly for
the antidepressants versus treatment as usual comparison in Sharp
2010, where both groups received the same usual care (supportive
visits with their GP).
The studies in this review are all from high-income countries, with
five of the six studies from UK or US settings. Conclusions therefore cannot be generalised to medium- and low- income settings, a
limitation given the elevated prevalence of perinatal mental disorders observed in these settings (Fisher 2012). Most of the women
in the included studies were also white Caucasian, which may
prevent results being applicable to ethnic minority populations.
Teenage mothers were also often excluded (Wisner 2006 included
women over 15 years of age and Yonkers 2008 included women
over 16 years of age; other studies were limited to women over
18 years). Again, this limits generalisation to a group particularly
vulnerable to postnatal depression (Figueiredo 2007).
The evidence is also limited by the small number of antidepressants individually assessed (four antidepressants only, of which
three were SSRIs) and the extremely limited data on longer-term,
infant and secondary outcomes. Response and remission rates varied substantially between studies, with relatively low rates even in
the antidepressant groups in some studies (e.g. Sharp 2010). This
is likely to reflect differences in study methodology (particularly
participant inclusion and exclusion criteria and length of follow
up) and adherence but should be considered when interpreting
findings. Studies of other antidepressants, including evaluation
of the impact of antidepressants on outcomes for breastfeeding
mothers and infants, would increase the evidence base on treatment options for postnatal women.
Quality of the evidence
The risk of bias varied between domains in the six trials included
in the review. Random sequence generation and blinding were
generally performed and reported adequately (with some exceptions), but assessment of allocation concealment and selective outcome reporting was problematic due to insufficient detail in most
included studies and lack of availability of study protocols. The
greatest limitations to the quality of evidence were issues with recruitment and attrition. Most studies experienced difficulties in
recruitment, leading to studies being underpowered to detect a
significant treatment effect, and many also had high rates of dropout (the highest being 56% drop-out in Yonkers 2008). Although
ITT analysis is reported for all primary outcomes in this review,
drop-out may have introduced bias particularly if reasons for dropout, such as clinical worsening, differed between groups. In addition, some secondary outcomes were not reported as ITT, which
is likely to have introduced bias for these data. The amount of attrition was generally well described, but the reasons for and timing
of drop-out were often insufficiently detailed to assess the likelihood of meaningful bias. In addition, adherence was low in many
studies (particularly Sharp 2010, where there was also substantial cross-over between the study groups). Future studies should
report more clearly on all areas of potential bias, with particular
focus on reducing and describing attrition. Assessing studies using
the GRADEpro criteria (see Summary of findings for the main
comparison; Table 1; Table 2; Table 3) showed that the quality
of the evidence for all comparisons was low or very low (low: antidepressant versus antidepressant; very low: antidepressant versus
placebo, antidepressants versus treatment as usual, antidepressants
versus listening visits). This demonstrates the uncertainty in the
estimates and the likelihood that further research will have an important impact on our confidence in the estimates of the effect
sizes or the effects themselves, or both. The evidence was limited
by the risk of bias and imprecision in the included study estimates.
As RRs were used for the primary outcome in this review but
not in any original papers, the conclusions here do not always
match those of the primary papers. For example, Hantsoo 2013
reported significant differences in response and remission between
the antidepressant and placebo group based on Chi2 tests; however,
the RRs for these data were not significant. This is due to the small
sample size and low precision in the estimate; the RRs themselves
suggest substantial benefit to the antidepressant group but the
95% CIs were very wide.
Potential biases in the review process
We believe that all relevant RCTs were identified by the systematic
review process. Extensive efforts were made to identify relevant
papers through database searches, citation tracking, and contacting
pharmaceutical companies and experts in the field for knowledge
of relevant papers or unpublished data. Our searches of clinical
trial registries identified one ongoing study that may meet criteria
for the review; this is described in the Characteristics of ongoing
studies table. We also identified two studies where data collection
has been completed but data are not yet available, these are listed
in the Characteristics of studies awaiting classification tables. We
also contacted authors of conference presentations identified by
the initial search results when there was no record of an associated
publication. Despite these efforts, it is possible that publication
bias may have influenced the review findings. This could not be
assessed (e.g. through funnel plots) owing to the small number of
studies.
Two review authors independently performed study screening,
data extraction and risk of bias assessment with a third review au-
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29
thor resolving any discrepancies remaining after discussion. We included one study with a dropout rate above 50% (Yonkers 2008).
This may have introduced bias; however, drop-out in this study
was balanced between the antidepressant and placebo groups, and
the findings of the paper were robust to sensitivity analyses assuming that all drop-outs were remitters or non-remitters. Owing to the small number of relevant studies, we believe that the
data from this trial were valuable, although its conclusions must
be interpreted with caution. A number of other updates to the
protocol were made (e.g. the specification of response/remission
as the primary depression outcomes, the inclusion of quality of
life as a secondary outcome and the increased sub-categorisation
of antidepressant types). We also updated the protocol so that
non-validated scales could be included as outcome measures (with
planned sensitivity analyses to examine the effect of non-validated
scales on findings). This change was made to reduce the potential
for bias or limitations to the evidence base from excluding these
measures, balanced against the need to assess the potential for
bias from including non-validated measures. While changes to the
protocol may introduce bias in the review process, most changes
made here had no impact on the current review as they related to
items that were not present in included studies (e.g. certain types
of antidepressants, non-validated scales). However, these changes
should benefit future updates of this review.
Agreements and disagreements with other
studies or reviews
Although the effectiveness of antidepressants as a treatment for
depression has been established in the general adult population
(Arroll 2005), there is a paucity of studies, particularly RCTs, examining this in the postnatal period. Our review includes similar
studies to those reported in a systematic review focused on SSRIs for postnatal depression (De Crescenzo 2014), although an
additional published study is reported here (Hantsoo 2013), and
De Crescenzo 2014 included a study comparing paroxetine only
with paroxetine plus CBT (Misri 2004), which did not meet out
inclusion criteria. De Crescenzo et al concluded that antidepressants appear to reduce postnatal depression effectively without severe adverse effects but emphasised limitations including the small
number of studies, high dropout rates, unrepresentative samples
and lack of long-term follow up or assessment of acceptability.
They also highlighted that there is insufficient evidence to demonstrate a superiority of SSRIs over other treatments. The addition
of Hantsoo 2013 in this review allowed us to conduct a small
meta-analysis comparing SSRIs with placebo, however our overall
conclusions are similar and also emphasise the limitations of the
evidence, particularly regarding potential adverse outcomes for the
mother and infant.
AUTHORS’ CONCLUSIONS
Implications for practice
The evidence base reported in this review is of very low quality
and includes only a small number of studies, which imposes significant limitations for conclusions on both efficacy and potential
adverse outcomes for the mother and baby. It is difficult to draw
implications for practice from the findings reported here, particularly due to the lack of evidence on child outcomes, which may be
particularly important for women with postnatal depression. The
trials included here focused on mild to moderate depression and
suggested that, while SSRIs were found to be significantly more
effective than placebo, there was little difference in effectiveness
when comparing antidepressants with psychological/psychosocial
interventions.
Women with mild to moderate depression should be informed
that there is no current evidence to suggest a clear difference between the effectiveness of antidepressants and psychological/psychosocial treatments; shared decision-making to weigh up the potential for benefits and harms for both the mother and child needs
to be implemented in treatment decisions. Women with severe or
chronic depression or suicidal ideation were excluded from several
of the included studies, which is also a major limitation for making clinical recommendations. Clinicians treating women with severe depression in the postnatal period will need to draw on the
evidence base for severe depression from outside of the postnatal
period as well as observational studies examining the impact of
antidepressant medication on breastfeeding infants (taking into
account the potential for confounding in non-randomised studies).
Implications for research
Postnatal depression is the most common complication of childbearing and is associated with substantial morbidity for the mother
and child. However, there are few randomised controlled trials
examining the effectiveness of antidepressant treatments in the
postnatal period and more trials in this period are needed. Further
research is particularly required to demonstrate the impact and
safety of antidepressant treatments in the postnatal period regarding child outcomes and long-term follow-up. This is of particular
importance for breastfeeding women and their infants, as positive
or negative effects related to antidepressant treatment may not
emerge immediately. The safety of antidepressants for the baby and
in breastfeeding are often critical concerns for women in the postnatal period, so these outcomes must be assessed and reported by
future research. Other outcomes that are meaningful for women,
such as maternal satisfaction, mother-child interactions and quality of life, also need to be evaluated, as does the severity of sideeffects experienced.
Future trials should try to address other limitations of the current evidence base, including small sample sizes and high attrition.
Reasons for non-participation and drop-out should be assessed in
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
30
detail in future studies and substantial efforts should be made to
reduce their impact, including realistic estimates of recruitment
and dropout rates in sample size calculations and study protocols.
Broader inclusion criteria (e.g. not excluding women with chronic
depression) could improve recruitment and also increase the generalisability of findings. It is particularly important to develop an
evidence base for women with severe/chronic depression or suicidal ideation in the postnatal period.
One study in this review allowed a choice of antidepressants (decision made by study GPs and participants) (Sharp 2010), and
future studies could compare treatment effects in a group randomised to a choice of antidepressant medications, compared with
women randomised to a specific antidepressant with no choice.
Fidelity to antidepressant and comparison treatments among trial
participants should also be assessed in all future trials. Further
research could also examine combination therapy in comparison
with either antidepressants or psychological therapy. Finally, future studies should examine whether psychological interventions
are more likely to prevent relapse than antidepressants; cognitive
and behavioural strategies acquired through psychological interventions may help prevent relapse when pharmacological treatment has been stopped but there has been little research in this
area.
ACKNOWLEDGEMENTS
We would like to thank the Trials Search Co-ordinator of
the Cochrane Collaboration Depression, Anxiety and Neurosis
Group, and Reinhard Wentz of the Institute of Child Health, for
assistance with developing the search strategy for this review.
We would also like to thank the authors of the previous version
of this review (Sara Hoffbrand, Louise Howard and Helen Crawley) and Wei Dai, Hui Li and Jin Huajie for their assistance with
translation.
CRG funding acknowledgement:
The National Institute for Health Research (NIHR) is the largest
single funder of the Cochrane Depression, Anxiety and Neurosis
Group.
Disclaimer:
The views and opinions expressed therein are those of the authors
and do not necessarily reflect those of the NIHR, National Health
Service or the Department of Health.
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Wisner KL, Hanusa BH, Perel JM, Peindl KS, Piontek
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Yonkers 2008 {published data only}
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Yonkers KA, Lin H, Howell HB, Heath AC, Cohen LS.
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References to studies excluded from this review
Bennett 2001 {published data only}
Bennett P. The costs and benefits of treatment of post-natal
depression in the community. National Research Register
2001.
Honey KL, Bennett P, Morgan M. A brief psychoeducational group intervention for postnatal depression.
British Journal of Clinical Psychology 2002;41:405–9.
Misri 2004 {published data only}
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Rojas 2007 {published data only}
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NCT02122393 {unpublished data only}
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Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
35
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Appleby 1997
Methods
Randomisation method: computer-generated random numbers
Analysis by ITT: yes (LOCF), in addition to analysis by completion
Power calculation: none stated
Participants
Setting: community-based: women on maternity wards were asked to allow assessment
of their mood in their homes 6-8 weeks later
Country: UK
Inclusion criteria: women who scored ≥ 10 on the EPDS at the screening visit were
assessed with the CIS-R and eligible to participate if they scored ≥ 12, as well as satisfying
research diagnostic criteria for major or minor depressive disorder
Exclusion criteria: chronic (> 2 years) or resistant depression, current drug or alcohol
misuse, severe illness requiring close monitoring or hospital admission, breastfeeding
Number recruited: 87
Number dropped out: 26
Number analysed: 87 (additional completers analysis with 61 participants)
Age (mean): fluoxetine + 1 counselling session 25.7 years; fluoxetine + 6 counselling
sessions 26.6 years; placebo + 1 counselling session 23.1 years; placebo + 6 counselling
sessions 26.0 years
Ethnicity: no details
Socioeconomic status: no details
Interventions
Women were randomly assigned to 1 of 4 groups:
• Fluoxetine + 1 session of counselling (22 women)
• Fluoxetine + 6 sessions of counselling (21 women)
• Placebo + 1 session of counselling (23 women)
• Placebo + 6 sessions of counselling (21 women)
Counselling was derived from CBT and structured to offer reassurance and practical
advice on areas of concern to depressed mothers
Outcomes
Assessments were carried out at week 1, 4 and 12
Outcome was effect on depressive symptoms as measured by mean scores on the CIS-R,
the HAM-D (week 1 and 12 only) and the EPDS
Notes
Funding source not given.
See footnote for abbreviations and description of outcome measures
Risk of bias
Bias
Authors’ judgement
Support for judgement
Random sequence generation (selection Low risk
bias)
“Subjects were allocated to one of four
treatment groups by using computer generated random numbers”
Allocation concealment (selection bias)
No details on allocation concealment given
Unclear risk
Antidepressant treatment for postnatal depression (Review)
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36
Appleby 1997
(Continued)
Blinding (performance bias and detection Low risk
bias)
of participants
“The counselling was delivered by a psychologist… supervised by a second psychiatrist, both were blind to drug treatment,
as were trial subjects”
Blinding (performance bias and detection Low risk
bias)
of personnel
“The counselling was delivered by a psychologist… supervised by a second psychiatrist, both were blind to drug treatment,
as were trial subjects”
Blinding (performance bias and detection Low risk
bias)
of outcome assessors
“The assessment interviews were conducted by a psychiatrist blind to subject
treatment group”
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk
“Drop-out rates were similar in the four
groups. Drop outs were younger than subjects who completed the study and more
likely to have an unemployed partner and
to have a planned pregnancy, but the groups
did not differ on initial psychiatric morbidity scores, employment, obstetric complications, parity, family history, or personal
history of depression, including postnatal
depression”
Of 87 total participants, 14/43 from the
fluoxetine plus counselling group dropped
out and 12/44 of the placebo plus counselling group dropped out
Details of dropout timings and reasons
were reported, but mainly “no reason
given”. Lack of improvement was the reason for 3 drop-outs in the fluoxetine group
but 0 in the placebo group. In contrast, 3
women in the placebo group but only 1
woman in the intervention group dropped
out due to side effects
Selective reporting (reporting bias)
Unclear risk
Protocol unavailable
Other bias
Unclear risk
No details given on adherence to medication
See footnote for abbreviations and description of outcome measures
Antidepressant treatment for postnatal depression (Review)
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37
Bloch 2012
Methods
Randomisation method: pharmacy-generated random serial numbers
Analysis by ITT: yes (LOCF)
Power calculation: yes
Participants
Setting: maternity ward and baby care centre
Country: Israel
Inclusion criteria: aged 18-45 years; met criteria for current MDD during screening and
baseline visit according to DSM-IV (Structured Clinical Interview for DSM-IV Axis I
disorders), onset of depression within 2 months of delivery
Exclusion criteria: MADRS score ≥ 30, suicidal ideation (MADRS item 10 score ≥ 5),
psychotic symptoms or bipolar disorder, current depressive episode > 6 months, current
treatment with antidepressants, 2 failed adequate trials of antidepressants, major physical
illness, alcoholism or drug use
Number recruited: 42
Number dropped after baseline assessment: 2 (both from placebo + BDP group)
Number dropped out by week 8: 4 from sertraline + BDP group; 3 from placebo + BDP
group (not including the 2 dropped out after baseline assessment)
Number analysed: 40 (2 participants who dropped out after baseline excluded)
Age: no data
Ethnicity: no data
Socioeconomic status: sertraline + BDP group: high income: 7/20 (35%), middle income: 10/20 (50%), low income: 3/20 (15%); placebo + BD group: high income: 4/20
(20%), middle income: 7/20 (35%), low income 9/20 (45%)
Interventions
Women were randomly assigned to 1 of 2 groups:
• Sertraline + BDP (20 women): sertraline dosage: week 1 25 mg once daily, week 2
50 mg once daily, week 4 increase to 100 mg if < 20% improvement in MADRS or no
improvement in CGI. Blinded Psychiatrist decision on whether to increase dose
• Placebo + BDP (22 women). Dummy pills identical to sertraline were delivered to
women according to the same protocol as the sertraline group along with BDP
BDP is a time-limited psychotherapeutic intervention that aims to enhance the patient’s
insights about repetitive circumstances
Outcomes
Outcome measures carried out at weeks 0, 2, 4, 6, 8, 12
Primary outcome: continuous change in depressive symptoms as measured by the
MADRS and EPDS during 8-week randomisation phase
Secondary outcomes: continuous change in MADRS and EPDS during open phase of
the study (weeks 8-12), proportion of women meeting response and remission status
at week 8 (response defined as > 50% reduction in MADRS or EPDS scores during
treatment and remission as a final score of < 10 on the MADRS or < 7 on the EPDS)
Other secondary ratings: measurements of symptom severity sing the Clinical Global
Impression scale (CGI-I, CGI-S), assessment of global mental health with the MHI and
assessment of adverse effects using the UKU Side Effect Rating Scale
Notes
This study was funded by an Independent Investigator Award to Dr Bloch from the
National Alliance for Research on Schizophrenia and Depression, Great Neck, New York
See footnote for abbreviations and description of outcome measures
Risk of bias
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(Continued)
Bias
Authors’ judgement
Support for judgement
Random sequence generation (selection Low risk
bias)
“The institution’s pharmacy-generated random patient serial numbers with active versus placebo ratio 1:1 were issued to the researchers and randomly assigned to eligible patients by the psychiatrist after the informed consent was signed”
Allocation concealment (selection bias)
Insufficient information given to be certain
of allocation concealment
Unclear risk
Blinding (performance bias and detection Low risk
bias)
of participants
“The second group received dummy pills
daily, identical in appearance to the active
pills, according to the same protocol as the
active group”
Blinding (performance bias and detection Unclear risk
bias)
of personnel
“The managing psychiatrist was blinded to
treatment condition... The managing psychiatrist was also asked at the end of the
full protocol to document her assessment
of whether the patient received active or
placebo pills, and indeed, was unable to
correctly guess this factor in every instance”
Blinding (performance bias and detection Unclear risk
bias)
of outcome assessors
No details given on who assessed outcomes
so unclear whether outcome assessors were
blinded
Incomplete outcome data (attrition bias)
All outcomes
Low risk
“Seven patients discontinued medication
between weeks 4 and 8, three from the
placebo group and four from the active
group. Discontinuation was due to lack of
motivation (n=4: placebo group, n=2; sertraline group, n=2) and clinical deterioration (n=3: placebo group, n=1; sertraline
group, n=2).”
42 participants were originally in the study,
2 participants dropped out of the placebo
group immediately after the baseline. 40
participants are included in the ITT
Selective reporting (reporting bias)
Unclear risk
Insufficient detail in protocol
Other bias
Unclear risk
“A pill count was conducted to monitor
compliance. Protocol violation was defined
as <80% compliance by pill count”
It is unclear whether the 7 patients who dis-
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Bloch 2012
(Continued)
continued medication are the only participants with low compliance
“The compliance for psychotherapy was
good: in the sertraline group, 92% of the
psychotherapy sessions were attended compared to 87% in the placebo group (P=NS)
[not significant]”
Hantsoo 2013
Methods
Randomisation method: unclear
Analysis by ITT: yes (LOCF for response and remission analyses) and by evaluable group
Power calculation: yes
Participants
Setting: mixed setting - recruitment via local obstetrician-gynaecologists, paediatricians,
mental health professionals, postnatal depression support groups, and advertisements in
local newspapers
Country: USA
Inclusion criteria: aged 18-45 years, depression onset reported within 3 months after
delivery, no psychotropic medication for 5 or more weeks, and given birth within the
last 12 months to an infant without serious medical issues. Participants were required
to have a diagnosis of postnatal depression based on the SCID, to score ≥ 18 and < 32
on the 19-item HAM-D and to have at least “moderate” symptoms on the severity of
illness rating of the CGI scale. Only English speaking women were eligible
Exclusion criteria: onset of MDD during pregnancy (indicated on the SCID), screened
positive for thyroid disease (unless thyroid condition stable), drug or alcohol dependence
in the last 6 months or positive urine drug test during screening, current or history of
psychotic disorder (Axis I, including bipolar type I), active suicidal ideation, any significant medical conditions, planning to become pregnant or past failed trial of sertraline
Number recruited: 38 (36 randomised after the placebo run-in week: 2 participants had
> 30% decline in HAM-D scores during the run-in week and were removed from the
study as per protocol)
Number dropped out: 7 dropped out by week 7 (final week)
Number analysed: 36 analysed on an ITT basis. Repeated analyses with evaluable group
had at least 3 post-randomisation assessments (33 women)
Age (mean ± SD): 30.8 ± 4.0 years, with no between-group differences; sertraline: 29.6
± 4.0 years; placebo: 31.7 ± 3.7 yearsS
Ethnicity: sertraline group: 16 Caucasian, 1 Hispanic; placebo group: 18 Caucasian,1
Hispanic
Years of education (mean ± SD): sertraline group: 14.4 ± 2.0 years; placebo group: 14.0
± 1.2 years
Interventions
All participants underwent a 1-week single-blind placebo lead-in. Participants who still
met the inclusion criteria and had had a less than 30% reduction in HAM-D scores were
randomly assigned to 1 of 2 groups:
• Sertraline: treatment commenced with 50 mg daily. Dosage was then increased as
tolerated by 1 capsule (50 mg) every 1-2 weeks until clinical remission was obtained or
up to a maximum of 4 capsules (200 mg) per day. The mean daily dose (± SD) at week
7 was 100.0 ± 54.0 mg
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Hantsoo 2013
(Continued)
• Placebo: dosage followed the pattern described above. The mean dose for the
placebo group at week 7 was 119.4 ± 51.8 mg
Outcomes
Primary outcomes: response in psychiatric symptoms: treatment response was defined as
a score of ≤ 10 on the HAM-D, at least a 50% decrease in HAM-D score from baseline,
and a score of “much improved” or “very much improved” on the improvement scale of
the CGI (after 6 weeks of treatment); remission defined as per criteria for response to
treatment in addition to a HAM-D score ≤ 7 (after 6 weeks of treatment)
Secondary outcomes: trends over time in depressive symptoms as rated by the HAMD and the EPDS, and in anxiety symptoms as rated by the HAM-A. The predominant
interest was the treatment group by linear time interaction
Notes
This study was funded by Pfizer (New York, NY, USA), the National Institute of Mental
Health (P50 MH099910 and K23 MH01830) and the National Institute of Drug Abuse
(K24 DA03031)
See footnote for abbreviations and description of outcome measures
Risk of bias
Bias
Authors’ judgement
Support for judgement
Random sequence generation (selection Unclear risk
bias)
“After the lead-in, all the subjects.. were
randomised to a 6-week, double-blind
trial”
Allocation concealment (selection bias)
No details given on allocation concealment
Unclear risk
Blinding (performance bias and detection Low risk
bias)
of participants
1 participant was excluded after the study
began due to accidental unblinding
Blinding (performance bias and detection Low risk
bias)
of personnel
“A research pharmacist was responsible for
creating a blinding table and distributing
the study drug; all other study personnel
remained blind to subject treatment status”
Blinding (performance bias and detection Low risk
bias)
of outcome assessors
“All other study personnel remained blind
to subject treatment status”
Incomplete outcome data (attrition bias)
All outcomes
“A total of 17 women were randomised
to the sertraline group and 19 were randomised to placebo, for a total of 36 women
in the intent-to-treat group. The reasons
for failure to the full 7 weeks included clinical deteriorating (n=3, all in the placebo
group), loss to follow-up (n=3), and accidental unblinding (n=1)”
There could have been an underestimation
Unclear risk
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Hantsoo 2013
(Continued)
of treatment effect as women dropping out
for clinical deterioration were all in the control group
Selective reporting (reporting bias)
Unclear risk
Protocol unavailable
Other bias
Unclear risk
No details given on adherence to medication
Sharp 2010
Methods
Randomisation method: web-based randomisation programme
Analysis by ITT: ITT, multiple imputation and complete-case analysis all employed
Participants
Setting: community-based: recruitment was from 77 general practices based in Bristol,
South London, and Manchester
Country: UK
Inclusion criteria: women aged ≥ 18 years who had a recent live birth and were living
with their baby were eligible for screening phase. After screening, deemed to be eligible
if: score of ≥ 13 on baseline EPDS, ICD-10 primary diagnosis of depression on the
CIS-R, proficient in English at a level to complete all research assessments and recently
delivered baby was < 26 weeks old
Exclusion criteria: stillbirth or neonatal death, baby > 26 weeks old, baby fostered or
adopted. Women were also not eligible if they had psychosis, alcohol or drug abuse, were
already receiving treatment for depression or were actively suicidal
Number recruited: 254
Number dropped out by week 4: antidepressants: 23/129, treatment as usual: 13/125
Number dropped out by week 18: antidepressants: 32/129, listening visits: 16/125
Number analysed: 218 primary analysis on an ITT basis at 4 weeks, 206 primary analysis
on an ITT basis at 18 weeks, also analysed as all 254 randomised
Age (mean ± SD): 29.3 ± 6.3 years
Ethnicity: white 196 (77.8%), black 29 (11.5%), Asian 13 (5.2%), other 14 (5.6%)
Socioeconomic status: highest educational qualification: none: 36 (14.8%), GCSE
(school exams taken at 16) 67 (27.5%), A level (school exams taken at 18) 32 (13.1%),
NVQ (National Vocational Qualification) 48 (19.7%), degree 61 (25.0%)
Interventions
Women were randomly assigned to 1 of 2 groups:
• Antidepressants (129 women). SSRI recommended as a first-line treatment;
however, a pragmatic approach whereby the GP and the woman agreed which
antidepressant medication should be prescribed was employed. Most women were
prescribed citalopram (68 women), fluoxetine (49 women) or sertraline (22 women).
Other antidepressants prescribed were amitriptyline (4 women), cipramil (1 woman),
clomipramine (1 woman), dosulepin (5 women), escitalopram (6 women), imipramine
(1 woman), iofepramine (1 woman), mirtazapine (4 women), paroxetine (7 women),
prothiaden (1 woman) and venlafaxine (2 women). Trial design allowed women to
receive the alternative intervention at any time after four weeks. 68 women in the
antidepressant arm requested listening visits after the 4-week follow-up. Of these, 64
had at least one visit. Adherence to treatment: at 4 weeks 56% of the women
Antidepressant treatment for postnatal depression (Review)
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Sharp 2010
(Continued)
randomised to antidepressants reported taking any antidepressants (59/106, only
calculated for those followed-up).
• Treatment as usual and listening visits (125 women). Listening visits commenced
about 4 weeks after randomisation to mimic waiting list times (4 weeks of treatment as
usual). Listening visits were delivered in a series of up to 8 sessions by trained research
health visitors. Women allocated listening visits were able to visit their GP for
antidepressants at any time during the study, but GPs could not prescribe
antidepressants until 4 weeks unless absolutely necessary
Outcomes
Timing of each outcome and relevant domain
All assessments carried out at week 0, 4 and 18
Primary outcome: assessment of remission of postnatal depression using EPDS < 13 at
follow-up
Secondary outcomes: change in depressive symptoms (EPDS) as continuous variable, physical and mental health assessment (SF-12), assessment of maternal functioning (MAMA), health-related quality of life (EQ-5D), quality of marital relationships
(GRIMS). If women had a male partner he was asked to complete the following: assessment of relationship with partner (GRIMS), assessment of paternal functioning (PAPA)
, general health assessment (GHQ and SF-12)
Notes
This study was funded by the National Institute for Health Research Health Technology
Assessment programme
See footnote for abbreviations and description of outcome measures
Risk of bias
Bias
Authors’ judgement
Support for judgement
Random sequence generation (selection Low risk
bias)
“Before the baseline home visit, the
women’s trial identification number, date
of birth and trial centre were entered into
a web-based randomisation program”
“The randomisation sequences was generated using a computer program with block
sizes of six, eight and ten, varied randomly”
Allocation concealment (selection bias)
“After eligibility had been determined and
consent had been obtained at the home
visit, the researcher telephoned the remote
computerised randomisation service and
responded to a series of questions by keying
numbers (e.g. patient identification number, baseline EPDS score) of the telephone
keypad”
“The methods of sequence generation were
concealed from the researchers involved in
enrolling and randomising the women into
the trial”
Low risk
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(Continued)
Blinding (performance bias and detection High risk
bias)
of participants
“Participants, researchers and those delivering the interventions were not blinded to
the treatment allocation”
Blinding (performance bias and detection High risk
bias)
of personnel
“Participants, researchers and those delivering the interventions were not blinded to
the treatment allocation”
Blinding (performance bias and detection High risk
bias)
of outcome assessors
“Participants, researchers and those delivering the interventions were not blinded to
the treatment allocation”
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk
“More women in the antidepressant group
withdrew or were lost to follow-up [4
weeks: antidepressants 23 (18%), listening
visits 13 (10%) p = 0.090; 18 weeks: antidepressants 32 (25%), listening visits 16
(13%) p = 0.015]”
Reasons for drop-out are not given and
characteristics of drop-outs are not given
separately by intervention group
Sensitivity analyses (including multiple imputation) were performed to examine the
impact of missing data. The imputation of
missing data had no material effect on the
results
Selective reporting (reporting bias)
High risk
All primary outcomes reported. Some evidence of selective outcome reporting from
the protocol where the HOME measure
and Bayley Scale of Infant Development are
pre-specified but not reported in the main
paper. Paternal measures are also detailed in
the protocol; these are detailed in the methods of the main paper and it is stated that
they will be discussed in a separate report,
but this could not be identified
Other bias
High risk
“At 4 weeks only 59 (56%) of the 106
women followed up among those randomised to the antidepressants and who
completed the [adherence] questionnaire
reported taking any antidepressants. In the
listening visits groups seven (6%) of the
112 women followed up also reported taking antidepressants... At the 18-week time
point, the numbers in each group who reported taking antidepressants during the
previous 4 weeks were 62 (64% of the 97
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Sharp 2010
(Continued)
followed up) and 37 (34% of 109 followed
up) in the antidepressants and listening visits groups, respectively”
Wisner 2006
Methods
Randomisation method: block randomisation with a sequence generated in SPSS
Analysis by ITT: yes for primary outcomes (response and remission), LOCF
Power calculation: yes
Participants
Setting: no details
Country: USA
Inclusion criteria: women aged 15-45 years with major depression within 4 weeks of
birth. Women with chronic depression (an episode on major depression beginning before
the index pregnancy) were also included after additional funding was obtained part-way
through the trial. Mothers had to present for treatment within 3 months of delivery and
score ≥ 18 on the HAM-D
Exclusion criteria: presence of any other Axis I disorder except generalised anxiety disorder or panic disorder, contraindications to TCA treatment, and concurrent psychiatric
treatment
Number recruited: 109
Number dropped out: 23 from the sertraline group (42%), 13 from the nortriptyline
group (24%)
Number analysed: ITT and analyses presented for 95 women who took the assigned
medication for at least 1 week and provided at least 1 week of follow-up data and 83
women who provided at least 3 weeks of follow-up data
Age: no data
Ethnicity: significantly more non-white women were randomly assigned to sertraline
(40%) than nortriptyline (19%) (Fisher exact test; P value = 0.02). There were no other
demographic differences between the 2 drug groups at baseline and no other details on
ethnicity of socio-economic status were given
Interventions
The aim was to compare the effect on postnatal depression symptoms of treatment with
sertraline compared with nortriptyline
Women were randomly assigned to 1 of 2 groups:
• Sertraline: the dosing began with 25 mg/day for 2 days. Thereafter, the doses was
increased to 50 mg/day and further increased until either response or side effects
prohibited further dose escalation. The maximum dose was 200 mg/day
• Nortriptyline: initial dose of 10 mg/day. This was then increased to 25 mg/day
and then further increased until either response or side effects prohibited further dose
escalation. Maximum dose was 150 mg/day
Outcomes
Followed up at weekly intervals for weeks 1-8, then again at week 24
Primary outcomes: response to treatment at 8 weeks (50% reduction in HAM-D from
baseline); remission of depression (HAM-D < 7 at week 8); continuous change in HAMD; severity of symptoms of depression (CGI scale at week 8); overall functioning as
measured by the GAS; issues in income, housing, relationships and work (SPQ)
Secondary outcome: side effects on the Asberg Side Effects Rating Scale in addition to
time to withdrawal due to side effects, obsessions and compulsions measured with the
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(Continued)
YBOCS, emergence of mania was screening for safety reasons using the Mania Rating
Scale (derived from the Schedule for Affective Disorders and Schizophrenia)
Notes
This study was funded by the National Institute of Mental Health
See footnote for abbreviations and description of outcome measures
Risk of bias
Bias
Authors’ judgement
Support for judgement
Random sequence generation (selection Low risk
bias)
“Subjects were randomised 1:1 to either
nortriptyline or sertraline in block of 8 to
12 with a sequence generated by SPSS”
Allocation concealment (selection bias)
No details given on allocation concealment
Unclear risk
Blinding (performance bias and detection Low risk
bias)
of participants
“Prescriptions were assembled by the research pharmacist. The nortriptyline and
sertraline were delivered in 2 doses, with
breakfast and at bedtime. The opaque, inert gelatine capsules contained either sertraline (AM)/placebo(HS) or placebo(AM)
/nortriptyline (HS)”
Blinding (performance bias and detection Low risk
bias)
of personnel
“The primary staff (side effects monitor,
mood symptom rater, and study psychiatrist) were blind to drug assignment until
project completion. The medication monitoring function (nurse) was separate from
(and blind to) the mood monitoring (interviewer)”
Blinding (performance bias and detection Low risk
bias)
of outcome assessors
“The primary staff (side effects monitor,
mood symptom rater, and study psychiatrist) were blind to drug assignment until
project completion”
Incomplete outcome data (attrition bias)
All outcomes
“Significantly more women who took sertraline compared with nortriptyline withdrew from the study in the first 8 weeks (23/
55 [42%] versus 13/54 [24%], respectively
[P = 0.02]). The proportion of women who
were lost to follow-up or withdrew by personal choice differed significantly (sertraline, 20%, vs. nortriptyline, 6%; Wilcoxon
χ 2 1 = 4.86; P =0.03). Other reasons for
withdrawal (side effects, hypomania occurrence, or clinical deterioration) did not dif-
High risk
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(Continued)
fer between the 2 drug groups”
It is unclear why the difference in withdrawal between study groups was so high but likely to cause bias in results
Selective reporting (reporting bias)
Unclear risk
Protocol unavailable
Other bias
Low risk
“Fourteen women had minimal drug in
their blood despite claims of compliance.
The results remained the same when data
from these 14 women were removed. Drug
assignment in the 14 women was distributed similarly between nortriptyline (n
= 9/51, 18%) and sertraline (n = 5/44,
11%; Fisher exact test, P = 0.29)”
Yonkers 2008
Methods
Randomisation method: pre-determined with a computer-generated schedule in blocked
sets of 4 and was stratified by site
Analysis by ITT: yes (LOCF for response and remission analyses)
Participants
Setting: community/secondary care. Women were recruited by advertisement or referral
from obstetric care providers
Country: USA
Inclusion criteria: aged ≥ 16 years, met diagnostic criteria for MDD with an onset in the
3 months post-delivery, had given birth within the previous 9 months and had a score
on the 17-item HAM-D of at least 16 at the initial visit. Women who were breastfeeding
were allowed to participate
Exclusion criteria: onset of MDD prior to delivery, current suicidal ideation with intent,
current (within the last 6 months) alcohol or drug abuse or dependence, current psychotic symptoms, lifetime diagnosis of schizophrenia, bipolar disorder or schizoaffective
disorder, currently receiving treatment (pharmacotherapy or psychotherapy) for a psychiatric disorder, currently pregnant, unwilling to be randomised or unable to attend
treatment visits at a participating site
Number recruited: 70 women (35 active treatment, 35 placebo)
Number dropped out by final week (week 8 ± 7 days): paroxetine group: 20/35 (57%);
placebo group: 23/35 (66%)
Number analysed: ITT analysis and evaluation at week 8 for results from 17 women in
paroxetine group and 14 women in the placebo group
Age (mean ± SD): paroxetine: mean 26.1 ± 6.5; placebo: 25.9 ± 6.5
Ethnicity: paroxetine: white: 18 (51.4%), black: 5 (14.3%), Hispanic: 11 (31.4%), other
1 (2.9%); placebo: white: 16 (45.7%), black: 4 (11.4%), Hispanic: 14 (40.0%), other 1
(2.9%)
Socioeconomic status: paroxetine: < 12 years of education: 11 (37.9%), > 12 years of
education: 18 (62.1%); placebo: < 12 years of education: 15 (53.6%), > 12 years of
education: 13 (46.4%)
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Yonkers 2008
(Continued)
Interventions
Women were randomly assigned to 1 of 2 groups:
• Paroxetine: week 1 and 2: 1 capsule (10 mg) of immediate release paroxetine daily;
week 3 and 4: 2 capsules (20 mg) of immediate release paroxetine daily unless side
effects limited an increase. Further increments to 30 mg by week 4 and then 40 mg by
week 6 were encouraged if improvement was assessed as < 30% compared with baseline
• Placebo: identical placebo administered according to same protocol as paroxetine
Outcomes
All primary outcomes listed were assessed at weeks 1, 2, 3, 4, 6 and for a final visit, at
week 8 (± 7 days)
Primary outcome: change in depressive symptoms measured by the HAM-D, CGI and
the Inventory of Depressive Symptomatology - Self-report scale
Secondary outcomes: rates of remission, defined as a HAM-D score of ≤ 8, and response,
defined as a CGI-Improvement scale score of 1 or 2; predictors of remission defined as
above; Social Adjustment as measured by the SAS; SF-36
Notes
This study was supported by a Collaborative Research Trial, Investigator-Initiated grant
from GlaxoSmithKline to Drs Yonkers and Cohen and by National Institute of Mental
Health grant MH01648 to Dr Yonkers
See footnote for abbreviations and description of outcome measures
Risk of bias
Bias
Authors’ judgement
Support for judgement
Random sequence generation (selection Low risk
bias)
“Subjects were randomly assigned to take
identical capsules of either paroxetine or
placebo. Random assignment was predetermined with a computer-generated schedule in blocked sets of 4 and was stratified
by site. A study statistician was responsible
for random assignment”
Allocation concealment (selection bias)
Insufficient details provided to be sure of
allocation concealment
Unclear risk
Blinding (performance bias and detection Low risk
bias)
of participants
“Subjects were instructed to take 1 capsule
(10mg of immediate-release paroxetine or
identical placebo)”
Blinding (performance bias and detection Low risk
bias)
of personnel
“A study statistician was responsible for
random assignment, and remaining study
staff were blind to group assignment.”
Blinding (performance bias and detection Low risk
bias)
of outcome assessors
“..remaining study staff were blind to group
assignment”
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(Continued)
Incomplete outcome data (attrition bias)
All outcomes
High risk
“Seventy women qualified for the study,
and 31 completed study treatment… Subjects withdrew from the active treatment
for the following reasons: 1 due to an adverse event (nausea), 6 due to lack of efficacy, including 1 subject who was psychiatrically hospitalised, 6 who were lost to
follow-up, 5 who felt well and no longer
desired treatment, 1 who became pregnant
and 1 who was noncompliant
In subjects randomly assigned to placebo, 4
left the study because of perceived adverse
events (rash, nausea, diarrhoea, headache),
7 discontinued because of lack of efficacy,
including 1 subject who required hospitalisation, 9 were lost to follow-up, 2 improved
and no longer desired treatment, and 1 subject moved”
“Given the high rate of dropout, we explored additional models to assess the robustness of remission results. These models
first assumed that all dropouts were remitters and then that they were all nonremitters. In both models, treatment with paroxetine remained significantly better than
treatment with placebo”
Drop out numbers are similar in the 2
groups and some reasons account for similar numbers across the 2 groups but for a
substantial proportion “lost to follow up”
the reason for drop-out is unknown. Sensitivity analyses only performed for the primary outcome
Selective reporting (reporting bias)
High risk
The Social Adjustment Scale and SF-36
were included in the methods but not reported in the results
Other bias
Unclear risk
“Pill counts revealed that, among women
assigned to paroxetine, 7 were noncompliant (took less than 80% of prescribed pills
at 1 visit, and 4 were non-compliant at 2
visits. One subject assigned to active treatment was discontinued due to on-going
lack of compliance; of the remaining subject, no others fell below the 80% compliance rate at more than 2 visits. Among subjects assigned to placebo, 10 were noncom-
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Yonkers 2008
(Continued)
pliant at 1 visit, 3 were noncompliant during at least 2 visits, and 1 was noncompliant on 4 occasions”
The potential bias was unclear as we do not
know whether non-compliant women were
taking 0% or 79% of their medication. It
is also not clear whether the numbers of
non-compliant participants were reported
for the study as a whole (26/70 women) or
only for those who did not drop out (26/
31 women)
Abbreviations: BPD: brief dynamic psychotherapy; CBT: cognitive behavioural therapy; CGI: Clinical Global Improvement; CISR: Revised Clinical Interview Schedule; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; EPDS:
Edinburgh Postnatal Depression Scale; GAS: Global Assessment Scale; GHQ: General Health Questionnaire; GRIMS: Golombok
Rust Inventory of Marital State; HAM-A: Hamilton Rating Scale for Anxiety; HAM-D: Hamilton Rating Scale for Depression;
ICD-10: International Classification of Disease Tenth Revision; ITT: intention to treat; LOCF: last observation carried forward;
MADRS: Montgomery-Åsberg Depression Rating Scale; MAMA: Maternal Adjustment and Maternal Attitudes; MDD: major
depressive disorder; MIH: Mental Health Index; PAPA: Preschool Age Psychiatric Assessment; SAS: Social Adjustment Scale; SCID:
Structured Clinical Interview for DSM-IV; SD: standard deviation; SF-12: 12-item Short Form; SF-36: 36-item Short Form; SPQ:
Social Problems Questionnaire; YBOCS: Yale-Brown Obsessive Compulsive Scale.
CIS-R is a structured diagnostic interview schedule for the diagnosis of common mental disorders. The CIS-R is widely used in
population and primary care surveys to provide estimates of depression.
CGI-Improvement Scale is a clinician-rated scale that assesses changes in symptoms. The scales are rated on a scale of 1 = very much
improved; 2 = much improved; 3 = minimally improved; 4 = no change; 5 = minimally worse; 6 = much worse or 7 = very much worse.
Each component of the CGI is rated separately and the scales do not yield a global score.
CGI-Severity of Illness measure is a clinician-rated scale that assess the severity of symptoms. The CGI-Severity of Illness is rated on
a scale of 1 = not at all ill; 2 = borderline mentally ill; 3 = mildly ill; 4 = moderately ill; 5 = markedly ill; 6 = severely ill or 7 = extremely
ill. The CGI-Improvement scale is a clinician-rated scale that assesses changes in symptoms. The scales are rated on a scale of 1 = very
much improved; 2 = much improved; 3 = minimally improved; 4 = no change; 5 = minimally worse; 6 = much worse or 7 = very much
worse. Each component of the CGI is rated separately and the scales do not yield a global score.
EPDS is a 10-item self administered screen for perinatal depression, validated in 20 languages. For each item, women are asked to
select 1 of 4 responses that most closely describe how they have felt over the past 7 days. Each response has a value of 0-3; scores for the
10 items are summed to give a total score between 0 and 30. The EPDS is the most widely used screening instrument for postpartum
depression and has a positive predictive value for postnatal major depression of 9-64% (with a cut-off score of 9/10) or 17-100% (with
a cut-off of 12/13). A cut-off score of 12/13 is used in most studies to indicate postpartum depression. The EPDS does not discriminate
levels of depression and additional information is required to meet diagnostic criteria for depression.
EQ-5D is a preference-based measure of health-related quality of life measured on 5 dimensions (i.e. mobility, self care, usual activities,
pain/discomfort and anxiety/depression), each rated on 3 levels (i.e. no problems, some problems and severe problems). Participants are
classified into 1 of 243 health states, each associated with a score that can be used to calculate quality-adjusted life years. The measure
has been extensively used in health economic evaluations and its psychometric properties are adequate.
GAS is a rating scale for evaluating the overall functioning of a person during a specified time period on a continuum from psychological
or psychiatric sickness to health.
GRIMS is a 28-item self complete questionnaire that assesses the quality of the relationship between a married or co-habitating couple.
HAM-A is a clinician-rated screening instrument that assesses the presence and severity of anxiety. Total scores are obtained by summing
the score of each item, 0-4 (symptom is absent, mild, moderate or severe). For the 14-item HAM-A version total scores range from 0
to 56. A score of 0-13 is indicative of no anxiety; 14-17 is indicative of mild anxiety; 18-24 is indicative of moderate anxiety and 2530 is indicative of severe anxiety.
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
50
HAM-D is a clinician rated screening instrument that assesses the presence and severity of depression. Total scores are obtained by
summing the score of each item, 0-4 ((symptom is absent, mild, moderate or severe) or 0-2 (absent, slight or trivial, or clearly present).
For the 17-item HAM-D version, total scores range from 0 to 54. A score of 0-6 is indicative of no depression, 7-17 is indicative of
mild depression, 18-24 is indicative of moderate depression and ≥ 25 is indicative of severe depression. For most raters, a total score
of ≤ 7 after treatment is a typical indicator of remission and a decrease of 50% or more from baseline is considered an indicator of a
clinically significant change.
MADRS is a diagnostic instrument that measures the severity of depressive episodes. Each response has a value of 0-6; scores for the
10 items are summed to give a total score between 0 and 60. A score of 0-6 is indicative of no depression, 7-19 is indicative of mild
depression; 20-34 is indicative of moderate depression and ≥ 35 is indicative of severe depression.
MAMA is a self administered questionnaire that examines perceptions of maternal adjustment and attitudes towards marital relationships
and the baby. The postnatal sub-scale of the MAMA questionnaire comprises 12 items rated on a 4-point scale from 1 = “not at all” to
4 = “very much”.
SF-12 is a 12-item self-complete questionnaire that measures functional health and well-being. The measure is a widely used and wellvalidated generic measure of functional quality of life.
SPQ is a 33-item self report questionnaire that covers 10 areas or domains, including housing conditions; occupation; financial status;
social and leisure activities; contacts with relatives, friends and neighbours; family functioning; child-parent interaction; relationship
with spouse or partner and legal matters. The individual items are rated on a 4-point scale ranging from 0 (no social difficulties/
satisfactory adjustment) to 3 (severe social difficulties/very poor adjustment).
Characteristics of excluded studies [ordered by study ID]
Study
Reason for exclusion
Bennett 2001
No antidepressant treatment
Misri 2004
Not comparing antidepressants with another intervention - both arms had same antidepressant (paroxetine vs.
paroxetine + cognitive behavioural therapy)
Rojas 2007
No consistent randomised comparison of antidepressants to another intervention (multicomponent intervention vs.
usual care)
Stein 2012
Ineligible study population
Suri 2005
Antidepressant treatment not randomised
Yu 2006
Not comparing antidepressants with another intervention - both arms had same antidepressant (paroxetine vs.
paroxetine + psychological intervention)
Zhao 2006
Not comparing antidepressants with another intervention - both arms had same antidepressant (fluoxetine vs.
fluoxetine + shugan powder)
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
51
Characteristics of studies awaiting assessment [ordered by study ID]
NCT00744328
Methods
8-week, double-blind, placebo-controlled randomised controlled trial
Participants
85 women
Interventions
Transdermal oestradiol (50-200 µg/day) compared with sertraline (25-200 mg/day) compared with placebo
Outcomes
Primary outcome measures include assessing the efficacy of oestradiol as a treatment for postpartum depression, and
efficacy in comparison to placebo and sertraline
Secondary outcome measures will include data on infant development using Bayley Scales of Infant Development,
mother-infant serum oestradiol and sertraline levels, quality of mother-infant interactions
Notes
The study (NCT00744328) is led by Professor Katherine Wisner in the USA, data collection has finished (terminated
early due to recruitment issues) and analysis is in progress
Contact information: Emily A. Pinheiro: emily.pinheiro@northwestern.edu
NCT02122393
Methods
24-week, single-blinded (outcome assessor) randomised controlled trial
Participants
45 women
Interventions
Sertraline compared with cognitive behavioural therapy compared with combined therapy
Outcomes
Beck Depression Inventory (primary outcome), Beck Anxiety Inventory, Parenting Stress Index (secondary outcome)
Notes
This study is led by Jeannette Milgrom and Alan W Gemmill in Melbourne, Australia. The clinicaltrials.gov record
states that data collection was completed in April 2005 (study retrospectively registered in April 2014) but correspondence with study authors indicated that the report is currently in progress and data are not yet available
Contact information: jeannette.milgrom@austin.org.au
Characteristics of ongoing studies [ordered by study ID]
NCT00602355
Trial name or title
Effectiveness of Sertraline Alone and Interpersonal Psychotherapy Alone in Treating Women with Postpartum
Depression
Methods
13-week, double-blind, placebo-controlled randomised controlled trial
Participants
The study is expected to enrol 100 women
Interventions
Sertraline 25-200 mg/day alone compared with interpersonal psychotherapy, administered as 50-minute
sessions every week for 13 weeks, compared with placebo
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
52
NCT00602355
(Continued)
Outcomes
Primary outcome measure is monitoring of depressive symptoms severity using Hamilton Depression Rating
Scale
Secondary outcomes include: monitoring of depressive symptoms using the Back Depression Inventory and
Edinburgh Postnatal Depression Scale, general illness severity using Clinical Global Impression scale and
social functioning assessed with Postpartum Adjustment Questionnaire and anxiety assessed by Hamilton
Rating Scale for Anxiety. Follow-up assessments are due to take place 3 and 6 months post intervention
Starting date
February 2008
Contact information
Jennifer Bowman-Reif: jennifer-bowman-reif@uiowa.edu
Notes
The study is led by Dr Caron Zlotnick in the USA and is due to be completed in 2014
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
53
DATA AND ANALYSES
Comparison 1. Selective serotonin re-uptake inhibitors versus placebo
Outcome or subgroup title
1 Response rate at post-treatment
2 Remission rate at post-treatment
No. of
studies
No. of
participants
3
3
146
146
Statistical method
Risk Ratio (M-H, Random, 95% CI)
Risk Ratio (M-H, Random, 95% CI)
Effect size
1.43 [1.01, 2.03]
1.79 [1.08, 2.98]
Comparison 2. Antidepressants versus treatment as usual
Outcome or subgroup title
1 Remission rate at post-treatment
No. of
studies
No. of
participants
1
Statistical method
Risk Ratio (M-H, Random, 95% CI)
Effect size
Totals not selected
Comparison 3. Antidepressants versus psychosocial therapy (listening visits)
Outcome or subgroup title
1 Remission rate at post-treatment
Comparison 4.
antidepressant)
No. of
studies
No. of
participants
1
Statistical method
Risk Ratio (M-H, Random, 95% CI)
Effect size
Totals not selected
Selective serotonin re-uptake inhibitors versus other pharmacological intervention (tricyclic
Outcome or subgroup title
1 Response rate at post-treatment
2 Remission rate at post-treatment
No. of
studies
1
1
No. of
participants
Statistical method
Risk Ratio (M-H, Random, 95% CI)
Risk Ratio (M-H, Random, 95% CI)
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Effect size
Totals not selected
Totals not selected
54
Comparison 5. Sensitivity analysis: excluding trials with combined treament
Outcome or subgroup title
1 SSRIs verus placebo:
outcome 1.1 response rate at
post-treatment
2 SSRIs versus placebo: outcome
1.2 remission rate at
post-treatment
No. of
studies
No. of
participants
2
106
Risk Ratio (M-H, Random, 95% CI)
1.62 [0.98, 2.67]
2
106
Risk Ratio (M-H, Random, 95% CI)
2.56 [1.31, 5.00]
Statistical method
Effect size
Comparison 6. Sensitivity analysis: removing studies with high dropout or high risk of bias in any domain
Outcome or subgroup title
1 SSRIs verus placebo:
outcome 1.1 response rate at
post-treatment
2 SSRIs versus placebo:outcome
1.2 remission rate at
post-treatment
No. of
studies
No. of
participants
2
76
Risk Ratio (M-H, Random, 95% CI)
1.52 [0.89, 2.58]
2
76
Risk Ratio (M-H, Random, 95% CI)
1.60 [0.86, 2.97]
Statistical method
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Effect size
55
Analysis 1.1. Comparison 1 Selective serotonin re-uptake inhibitors versus placebo, Outcome 1 Response
rate at post-treatment.
Review:
Antidepressant treatment for postnatal depression
Comparison: 1 Selective serotonin re-uptake inhibitors versus placebo
Outcome: 1 Response rate at post-treatment
Study or subgroup
SSRIs
Placebo
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
n/N
n/N
Bloch 2012 (1)
14/20
11/20
51.2 %
1.27 [ 0.78, 2.08 ]
Hantsoo 2013 (2)
10/17
5/19
16.9 %
2.24 [ 0.95, 5.24 ]
Yonkers 2008 (3)
15/35
11/35
31.8 %
1.36 [ 0.73, 2.54 ]
Total (95% CI)
72
74
100.0 %
1.43 [ 1.01, 2.03 ]
Total events: 39 (SSRIs), 27 (Placebo)
Heterogeneity: Tau2 = 0.0; Chi2 = 1.33, df = 2 (P = 0.51); I2 =0.0%
Test for overall effect: Z = 2.01 (P = 0.045)
Test for subgroup differences: Not applicable
0.1 0.2
0.5
Favours placebo
1
2
5
10
Favours SSRIs
(1) Sertraline and psychological therapy (brief dynamic psychotherapy) versus placebo and psychological therapy (brief dynamic psychotherapy)
(2) Sertraline versus placebo
(3) Paroxetine versus placebo
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
56
Analysis 1.2. Comparison 1 Selective serotonin re-uptake inhibitors versus placebo, Outcome 2 Remission
rate at post-treatment.
Review:
Antidepressant treatment for postnatal depression
Comparison: 1 Selective serotonin re-uptake inhibitors versus placebo
Outcome: 2 Remission rate at post-treatment
Study or subgroup
SSRI
Placebo
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
n/N
n/N
Bloch 2012 (1)
13/20
10/20
52.7 %
1.30 [ 0.75, 2.24 ]
Hantsoo 2013 (2)
9/17
4/19
22.4 %
2.51 [ 0.94, 6.70 ]
Yonkers 2008 (3)
13/35
5/35
24.9 %
2.60 [ 1.04, 6.52 ]
Total (95% CI)
72
74
100.0 %
1.79 [ 1.08, 2.98 ]
Total events: 35 (SSRI), 19 (Placebo)
Heterogeneity: Tau2 = 0.05; Chi2 = 2.61, df = 2 (P = 0.27); I2 =23%
Test for overall effect: Z = 2.25 (P = 0.025)
Test for subgroup differences: Not applicable
0.1 0.2
0.5
Favours placebo
1
2
5
10
Favours SSRIs
(1) Sertraline and psychological therapy (brief dynamic psychotherapy) versus placebo and psychological therapy (brief dynamic psychotherapy)
(2) Sertraline versus placebo
(3) Paroxetine versus placebo
Analysis 2.1. Comparison 2 Antidepressants versus treatment as usual, Outcome 1 Remission rate at posttreatment.
Review:
Antidepressant treatment for postnatal depression
Comparison: 2 Antidepressants versus treatment as usual
Outcome: 1 Remission rate at post-treatment
Study or subgroup
Sharp 2010
Antidepressants
Treatment as usual
n/N
n/N
48/129
22/125
Risk Ratio
MH,Random,95%
CI
Risk Ratio
MH,Random,95%
CI
2.11 [ 1.36, 3.28 ]
0.1 0.2
0.5
Favours treatment as usual
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
2
5
10
Favours antidepressants
57
Analysis 3.1. Comparison 3 Antidepressants versus psychosocial therapy (listening visits), Outcome 1
Remission rate at post-treatment.
Review:
Antidepressant treatment for postnatal depression
Comparison: 3 Antidepressants versus psychosocial therapy (listening visits)
Outcome: 1 Remission rate at post-treatment
Study or subgroup
Sharp 2010
Antidepressants
Listening visits
n/N
n/N
60/129
56/125
Risk Ratio
MH,Random,95%
CI
Risk Ratio
MH,Random,95%
CI
1.04 [ 0.79, 1.36 ]
0.1 0.2
0.5
1
Favours listening visits
2
5
10
Favours antidepressants
Analysis 4.1. Comparison 4 Selective serotonin re-uptake inhibitors versus other pharmacological
intervention (tricyclic antidepressant), Outcome 1 Response rate at post-treatment.
Review:
Antidepressant treatment for postnatal depression
Comparison: 4 Selective serotonin re-uptake inhibitors versus other pharmacological intervention (tricyclic antidepressant)
Outcome: 1 Response rate at post-treatment
Study or subgroup
Wisner 2006
Sertraline
Nortriptyline
n/N
n/N
31/55
37/54
Risk Ratio
MH,Random,95%
CI
Risk Ratio
MH,Random,95%
CI
0.82 [ 0.61, 1.10 ]
0.1 0.2
0.5
Favours nortriptyline
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
2
5
10
Favours sertraline
58
Analysis 4.2. Comparison 4 Selective serotonin re-uptake inhibitors versus other pharmacological
intervention (tricyclic antidepressant), Outcome 2 Remission rate at post-treatment.
Review:
Antidepressant treatment for postnatal depression
Comparison: 4 Selective serotonin re-uptake inhibitors versus other pharmacological intervention (tricyclic antidepressant)
Outcome: 2 Remission rate at post-treatment
Study or subgroup
Sertraline
Wisner 2006
Nortriptyline
n/N
n/N
25/55
26/54
Risk Ratio
MH,Random,95%
CI
Risk Ratio
MH,Random,95%
CI
0.94 [ 0.63, 1.41 ]
0.1 0.2
0.5
Favours nortriptyline
1
2
5
10
Favours sertraline
Analysis 5.1. Comparison 5 Sensitivity analysis: excluding trials with combined treament, Outcome 1 SSRIs
verus placebo: outcome 1.1 response rate at post-treatment.
Review:
Antidepressant treatment for postnatal depression
Comparison: 5 Sensitivity analysis: excluding trials with combined treament
Outcome: 1 SSRIs verus placebo: outcome 1.1 response rate at post-treatment
Study or subgroup
SSRI
n/N
n/N
Hantsoo 2013
10/17
5/19
34.8 %
2.24 [ 0.95, 5.24 ]
Yonkers 2008
15/35
11/35
65.2 %
1.36 [ 0.73, 2.54 ]
52
54
100.0 %
1.62 [ 0.98, 2.67 ]
Total (95% CI)
Placebo
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
Total events: 25 (SSRI), 16 (Placebo)
Heterogeneity: Tau2 = 0.0; Chi2 = 0.85, df = 1 (P = 0.36); I2 =0.0%
Test for overall effect: Z = 1.88 (P = 0.060)
Test for subgroup differences: Not applicable
0.01
0.1
Favours placebo
1
10
100
Favours SSRIs
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
59
Analysis 5.2. Comparison 5 Sensitivity analysis: excluding trials with combined treament, Outcome 2 SSRIs
versus placebo: outcome 1.2 remission rate at post-treatment.
Review:
Antidepressant treatment for postnatal depression
Comparison: 5 Sensitivity analysis: excluding trials with combined treament
Outcome: 2 SSRIs versus placebo: outcome 1.2 remission rate at post-treatment
Study or subgroup
SSRI
n/N
n/N
Hantsoo 2013
9/17
4/19
46.8 %
2.51 [ 0.94, 6.70 ]
Yonkers 2008
13/35
5/35
53.2 %
2.60 [ 1.04, 6.52 ]
52
54
100.0 %
2.56 [ 1.31, 5.00 ]
Total (95% CI)
Placebo
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
Total events: 22 (SSRI), 9 (Placebo)
Heterogeneity: Tau2 = 0.0; Chi2 = 0.00, df = 1 (P = 0.96); I2 =0.0%
Test for overall effect: Z = 2.75 (P = 0.0060)
Test for subgroup differences: Not applicable
0.01
0.1
Favours placebo
1
10
100
Favours SSRIs
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
60
Analysis 6.1. Comparison 6 Sensitivity analysis: removing studies with high dropout or high risk of bias in
any domain, Outcome 1 SSRIs verus placebo: outcome 1.1 response rate at post-treatment.
Review:
Antidepressant treatment for postnatal depression
Comparison: 6 Sensitivity analysis: removing studies with high dropout or high risk of bias in any domain
Outcome: 1 SSRIs verus placebo: outcome 1.1 response rate at post-treatment
Study or subgroup
SSRI
Placebo
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
n/N
n/N
Bloch 2012
14/20
11/20
68.6 %
1.27 [ 0.78, 2.08 ]
Hantsoo 2013
10/17
5/19
31.4 %
2.24 [ 0.95, 5.24 ]
37
39
100.0 %
1.52 [ 0.89, 2.58 ]
Total (95% CI)
Total events: 24 (SSRI), 16 (Placebo)
Heterogeneity: Tau2 = 0.04; Chi2 = 1.35, df = 1 (P = 0.24); I2 =26%
Test for overall effect: Z = 1.55 (P = 0.12)
Test for subgroup differences: Not applicable
0.01
0.1
Favours placebo
1
10
100
Favours SSRIs
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
61
Analysis 6.2. Comparison 6 Sensitivity analysis: removing studies with high dropout or high risk of bias in
any domain, Outcome 2 SSRIs versus placebo:outcome 1.2 remission rate at post-treatment.
Review:
Antidepressant treatment for postnatal depression
Comparison: 6 Sensitivity analysis: removing studies with high dropout or high risk of bias in any domain
Outcome: 2 SSRIs versus placebo:outcome 1.2 remission rate at post-treatment
Study or subgroup
SSRI
Placebo
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
n/N
n/N
13/20
10/20
68.6 %
1.30 [ 0.75, 2.24 ]
Hantsoo 2013
9/17
4/19
31.4 %
2.51 [ 0.94, 6.70 ]
Total (95% CI)
37
39
100.0 %
1.60 [ 0.86, 2.97 ]
Bloch 2012
Total events: 22 (SSRI), 14 (Placebo)
Heterogeneity: Tau2 = 0.07; Chi2 = 1.42, df = 1 (P = 0.23); I2 =30%
Test for overall effect: Z = 1.48 (P = 0.14)
Test for subgroup differences: Not applicable
0.01
0.1
1
Favours placebo
10
100
Favours SSRIs
ADDITIONAL TABLES
Table 1. Summary of results and GRADE assessments
Antidepressants compared with treatment as usual for postnatal depression
Outcomes
Raw data by group Relative effect
% (no of women) (95% CI)
Remission
Antidepressants:
37% (48/129)
Treatment as usual:
18% (22/125)
No of participants
(studies)
Sharp 2010:
254 (1 study)
RR 2.11 (1.36 to 3.
28)
Quality of the evi- Comments
dence
(GRADE)
⊕
very low1,2
Sharp 2010: remission: < 13 EPDS (4
weeks)
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change
the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to
change the estimate.
Very low quality: We are very uncertain about the estimate.
1
downgraded twice due to high risk of bias in two domains (lack of blinding of outcome assessors and low adherence)
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
62
2
downgraded due to imprecision (only one study available for this comparison)
EPDS: Edinburgh Postnatal Depression Scale; RR: risk ratio.
Table 2. Summary of results and GRADE assessments
Antidepressants compared with listening visits for postnatal depression
Outcomes
Raw data by group Relative effect
% (no of women) (95% CI)
Remission
Antidepressants:
47% (60/129)
Listening visits:
45% (56/125)
No of participants
(studies)
Sharp 2010:
254
RR 1.04 (0.79 to 1. (1 study)
36)
Quality of the evi- Comments
dence
(GRADE)
⊕
very low1,2
Sharp 2010: remission: < 13 EPDS (18
weeks)
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change
the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to
change the estimate.
Very low quality: We are very uncertain about the estimate.
1
downgraded twice due to high risk of bias in two domains (lack of blinding of outcome assessors and low adherence)
downgraded due to imprecision (only one study available for this comparison)
EPDS: Edinburgh Postnatal Depression Scale; RR: risk ratio.
2
Table 3. Summary of results and GRADE assessments
Antidepressant (sertraline) compared with other antidepressant (nortriptyline) for postnatal depression
Outcomes
Raw data by group Relative effect
% (no of women) (95% CI)
No of participants
(studies)
Response
Sertraline:
56% (31/55)
Nortriptyline:
69% (37/54)
Wisner 2006:
109
RR 0.82 (0.61 to 1. (1 study)
10)
⊕⊕
low1,2
Wisner
2006:
response: 50% reduction in HAM-D
from baseline (at 8
weeks)
Remission
Sertraline:
46% (25/55)
Nortriptyline:
48% (26/54)
Wisner 2006:
109
RR 0.94 (0.63 to 1. (1 study)
41)
⊕⊕
low1,2
Wisner 2006: remission: HAM-D <
7 (at 8 weeks)
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Quality of the evi- Comments
dence
(GRADE)
63
Table 3. Summary of results and GRADE assessments
(Continued)
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change
the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to
change the estimate.
Very low quality: We are very uncertain about the estimate.
1
downgraded due to risk of bias (incomplete outcome data owing to loss to follow-up)
downgraded due to imprecision (only 1 study available for this comparison)
HAM-D: Hamilton Rating Scale for Depression; RR: risk ratio.
2
WHAT’S NEW
Last assessed as up-to-date: 11 July 2014.
Date
Event
Description
5 September 2014
New citation required and conclusions have changed
Review updated
5 September 2014
New search has been performed
Review updated, new searches conducted and new studies included
HISTORY
Protocol first published: Issue 2, 2000
Review first published: Issue 2, 2001
Date
Event
Description
1 November 2008
Amended
Converted to new review format.
12 January 2001
New citation required and conclusions have changed
Substantive amendment
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
64
CONTRIBUTIONS OF AUTHORS
KT (Kylee Trevillion), LH (Louise M Howard) and EM (Emma Molyneaux) developed the protocol.
KT, HM (Helen McGeown) and AK (Amar Karia) carried out searches and screening.
HM and AK conducted the data extraction.
EM, HM and AK conducted risk of bias assessment.
HM, EM, KT, AK and LH wrote the results and conclusion.
DECLARATIONS OF INTEREST
Louise M Howard is Chair of the National Institute for Health and Care Excellence (NICE) (update) guideline on antenatal and
postnatal mental health. She is Chief Investigator of an NIHR Programme Grant for Applied Research on the effectiveness of perinatal
mental health services (RP- RP-DG-1108-10012) and has funding from an NIHR Research Professorship on maternal mental health,
and a grant from Tommy’s baby charity (with the support of a corporate social responsibility grant from Johnson & Johnson) on
antipsychotics in pregnancy. Her work is also supported by the NIHR Mental Health Biomedical Research Centre at the South London
and Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the author and not necessarily
those of the NHS, the NIHR or the Department of Health.
Kylee Trevillion is project manager on an NIHR Programme Grant for Applied Research on the effectiveness of perinatal mental health
services (RP- RP-DG-1108-10012).
Emma Molyneaux is supported by a Medical Research Council (MRC) PhD Studentship and Tommy’s baby charity.
There are no other declarations of interest.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW
This update of the review includes an updated background, additional information on the included studies and participants, and
uses the Cochrane ’Risk of bias’ assessment tool. We have updated the primary outcome; this was originally “clinically significant
improvement in depression”, which was not specifically defined by many papers. We also added severity of depression and quality of
life as additional secondary outcomes. Based on peer reviewer comments, we altered the inclusion criteria so that non-validated scales
can be included as outcomes (but will be excluded in sensitivity analyses if meta-analyses are conducted in future updates of this review
to examine their impact on findings). This does not affect the data included in this review. The ’other’ category of antidepressants
has been separated into the separate types included to reflect the diversity of antidepressants previous included in this single category.
Again, this does not alter the analyses in this review, as we identified no studies including these antidepressants. The original protocol
planned sub-group analyses for women with a history of bipolar disorder, which was not included in the current study owing to the
lack of relevant studies. The original protocol stated that studies with greater than 50% drop-out would not be eligible for the review.
However, owing to the small evidence base, we decided to include studies with greater than 50% drop-out (Yonkers 2008 reported a
56% drop-out rate).
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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INDEX TERMS
Medical Subject Headings (MeSH)
Antidepressive Agents, Second-Generation [∗ therapeutic use]; Clinical Trials as Topic; Depression, Postpartum [∗ drug therapy]; Fluoxetine [∗ therapeutic use]; Serotonin Uptake Inhibitors [∗ therapeutic use]
MeSH check words
Female; Humans
Antidepressant treatment for postnatal depression (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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