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Cited by 171Maternal Mental Health During Pregnancy and PostpartumTreatment of Major DepressionPregnancy and Medication Impact

Antidepressant treatment for postnatal depression

Open access
Molyneaux, Emma, Howard, Louise M, McGeown, Helen R, Karia, Amar M, Trevillion, Kylee·2014·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd002018.pub2PMC PMC10589908
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Abstract

BACKGROUND: Depression is one of the most common morbidities of the postnatal period. It has been associated with adverse outcomes for women, children, the wider family and society as a whole. Treatment is with psychosocial interventions or antidepressant medication, or both. The aim of this review is to evaluate the effectiveness of different antidepressants and to compare their effectiveness with placebo, treatment as usual or other forms of treatment. This is an update of a review last published in 2014. OBJECTIVES: To assess the effectiveness and safety of antidepressant drugs in comparison with any other treatment (psychological, psychosocial, or pharmacological), placebo, or treatment as usual for postnatal depression. SEARCH METHODS: We searched Cochrane Common Mental Disorders's Specialized Register, CENTRAL, MEDLINE, Embase and PsycINFO in May 2020. We also searched international trials registries and contacted experts in the field. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of women with depression during the first 12 months postpartum that compared antidepressant treatment (alone or in combination with another treatment) with any other treatment, placebo or treatment as usual. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from the study reports. We requested missing information from study authors wherever possible. We sought data to allow an intention-to-treat analysis. Where we identified sufficient comparable studies we pooled data and conducted random-effects meta-analyses. MAIN RESULTS: We identified 11 RCTs (1016 women), the majority of which were from English-speaking, high-income countries; two were from middle-income countries. Women were recruited from a mix of community-based, primary care, maternity and outpatient settings. Most studies used selective serotonin reuptake inhibitors (SSRIs), with treatment duration ranging from 4 to 12 weeks. Meta-analysis showed that there may be a benefit of SSRIs over placebo in response (55% versus 43%; pooled risk ratio (RR) 1.27, 95% confidence interval (CI) 0.97 to 1.66); remission (42% versus 27%; RR 1.54, 95% CI 0.99 to 2.41); and reduced depressive symptoms (standardised mean difference (SMD) -0.30, 95% CI -0.55 to -0.05; 4 studies, 251 women), at 5 to 12 weeks' follow-up. We were unable to conduct meta-analysis for adverse events due to variation in the reporting of this between studies. There was no evidence of a difference between acceptability of SSRI and placebo (27% versus 27%; RR 1.10, 95% CI 0.74 to 1.64; 4 studies; 233 women). The certainty of all the evidence for SSRIs was low or very low due to the small number of included studies and a number of potential sources of bias, including high rates of attrition. There was insufficient evidence to assess the efficacy of SSRIs compared with other classes of antidepressants and of antidepressants compared with other pharmacological interventions, complementary medicines, psychological and psychosocial interventions or treatment as usual. A substantial proportion of women experienced adverse effects but there was no evidence of differences in the number of adverse effects between treatment groups in any of the studies. Data on effects on children, including breastfed infants, parenting, and the wider family were limited, although no adverse effects were noted. AUTHORS' CONCLUSIONS: There remains limited evidence regarding the effectiveness and safety of antidepressants in the management of postnatal depression, particularly for those with more severe depression. We found low-certainty evidence that SSRI antidepressants may be more effective in treating postnatal depression than placebo as measured by response and remission rates. However, the low certainty of the evidence suggests that further research is very likely to have an important impact on our effect estimate. There is a continued imperative to better understand whether, and for whom, antidepressants or other treatments are more effective for postnatal depression, and whether some antidepressants are more effective or better tolerated than others. In clinical practice, the findings of this review need to be contextualised by the extensive broader literature on antidepressants in the general population and perinatal clinical guidance, to inform an individualised risk-benefit clinical decision. Future RCTs should focus on larger samples, longer follow-up, comparisons with alternative treatment modalities and inclusion of child and parenting outcomes.

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  • A recent meta-analysis of controlled clinical trials of selective serotonin reuptake inhibitors in postpartum depression reported that the strength of available evidence was low and inconclusive about whether selective serotonin reuptake inhibitors were more effective than psychosocial intervention, while demonstrating higher response and remission rates than placebo.

    “A recent meta-analysis of controlled clinical trials of selective serotonin reuptake inhibitors in PPD reported that the strength of available evidence was low and inconclusive of whether selective serotonin reuptake inhibitors were more effective than psychosocial intervention, while demonstrating higher response and remission rates than placebo.55”

    From Effect of Zuranolone vs Placebo in Postpartum Depression (2021) · cites this paper as [55]

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Research works printed but not linked: 5

  1. Yonkers 2008 {published data only} Heath AC, Yonkers KA, Rush AJ. Paroxetine in the treatment of postpartum depression. Proceedings of the 153rd Annual Meeting of the American Psychiatric Association; 2000 May 13-8;
  2. Heath AC, Yonkers KA, Rush AJ. Paroxetine in the treatment of postpartum depression. Proceedings of the 155th Annual Meeting of the American Psychiatric Association; 2002 May 18-23; Philadelphia, PA. 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.
  3. Yu 2006 {published data only} Yu H, Liu C, Wang X. The therapeutic effects of paroxetine addition of psychological intervention on post-partum depression. Progress in Obstetrics and Gynecology 2006;15(4):289-91.
  4. Zhao 2006 {published data only} Zhao X, Lin H. Study on postpartum depression treated with combination of fluoxetine and Chaihu Shugan powder. Liaoning Journal of Traditional Chinese Medicine 2006;33(5):586-7. References to studies awaiting assessment NCT00744328 {unpublished data only} Wisner KL. Postpartum Depression: Transdermal Estradiol Versus Sertraline (E2 SERT). http://clinicaltrials.gov/show/ NCT00744328 2014 (accessed 04 August 2014).
  5. Wisner KL. Should estradiol be prescribed for postpartum depression? [conference abstract]. Biological Psychiatry 2014;9(Suppl 1):299S.

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Authors
Molyneaux, E., Howard, L. M., McGeown, H. R., Karia, A. M., & Trevillion, K.
Affiliations
King's College London (GB)
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2014-09-11
Volume
2014
Issue
9
Pages
CD002018-CD002018
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd002018.pub2
PMC
PMC10589908
OpenAlex
W3023792194
Cited by
171
References
97
Citations by year
2026: 1 · 2025: 10 · 2024: 18 · 2023: 21 · 2022: 17 · 2021: 14 · 2020: 12 · 2019: 14 · 2018: 15 · 2017: 8 · 2016: 8 · 2015: 15 · 2014: 1 · 2013: 3
FWCI
1.67
Type
journal article
Language
en
Open access
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Research Portal (King's College London) (submittedVersion)
Funders
National Institute for Health and Care Research (NIHR-RP-R3-12-011)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Maternal Mental Health During Pregnancy and Postpartum
  • Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Pregnancy and Medication Impact
Keywords
postpartum depression, antidepressants, selective serotonin reuptake inhibitors, tricyclic antidepressants, mirtazapine, nortriptyline, fluoxetine, sertraline, placebo comparison, remission, depressive symptoms, adverse effects, drug safety, treatment effectiveness, psychosocial interventions, postpartum period, maternal mental health, child outcomes
MeSH terms
Adult, Clinical Trials as Topic, Female, Fluoxetine, Humans, Nortriptyline, Randomized Controlled Trials as Topic, Selective Serotonin Reuptake Inhibitors, Paroxetine, Antidepressive Agents, Second-Generation, Depression, Postpartum, Sertraline

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