Antidepressant treatment for postnatal depression

Review question

In this Cochrane Review, we wanted to find out how well antidepressants work for treating women with postnatal depression.

Why this is important

Postnatal depression is depression that starts within 12 months of a woman having a baby. Many women are affected. Postnatal depression can have serious short- and long-term effects on the mother, the baby, and the family as a whole.

There are several ways to treat postnatal depression. These include antidepressant medication, psychological therapy, support or counselling. The type of treatment offered depends on how severe the depression is, other illnesses and the woman's choice. In general, women who are pregnant or breastfeeding are often anxious about the potential unwanted effects of antidepressant medicines on their  baby.

It is important to know whether antidepressants could be an effective and acceptable treatment for women with postnatal depression.

What we did

In May 2020, we searched for studies of antidepressants for women with postnatal depression. We looked for randomised controlled trials, in which treatments were given to study participants at random. These studies give the most reliable evidence.

We included 11 studies involving 1016 women. The studies compared antidepressants with placebo (dummy pill), treatment as usual (watch and wait, regular visits with a care co-ordinator), psychological interventions (therapy), psychosocial interventions (peer support or counselling), any other other medicines or another type of antidepressant; and complementary medicine (food supplements).

Eight of the studies were conducted in English-speaking, high-income countries. The length of treatment ranged from four to 24 weeks.

The outcomes we focused on were how well the treatments worked (effectiveness). This was measured by the number of people who responded well to treatment (response) or no longer met criteria for depression at the end of treatment (remission). We also looked at whether women and/or their babies experienced adverse effects with the treatment.

What did we find?

We found that women treated with antidepressants may respond slightly better and have less severe postnatal depression than women given a placebo. The number of unwanted effects experienced by women was similar between groups. There were not enough studies comparing antidepressants with other types of treatment. The most commonly studied antidepressants were from the 'SSRI' (serotonin specific reuptake inhibitor) group.

Conclusions

This review found only a few relevant studies. There is some evidence that antidepressants may work better than a dummy pill for women with postnatal depression. There is not enough evidence comparing antidepressants to other treatments for postnatal depression. Clinicians need to consider study evidence from the general population and current clinical guidelines, along with the woman's illness history and current symptoms, to make an individualised risk-benefit treatment decision with the woman.

Certainty of the evidence

Our certainty (confidence) in the evidence is low. Some findings are based on only a few studies, with a small number of women in each treatment group. Therefore, we are not sure how reliable the results are. Our conclusions may change if more studies are conducted. Our finding that antidepressants may work better than a dummy pill is similar to findings from a larger number of studies in the general population.

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.  

Read the full 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 strategy: 

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.

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