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Commentary

Commentary on a Cochrane
Review of Antidepressants for
Postpartum Depression

E
RHODA REDULLA

Editors note: Cochrane Reviews are systematic


reviews of research in health care and health
Photos left: SI Photography, right: Diego Cervo / thinkstockphotos.com

policy that are published in the Cochrane professionals involved in delivering, leading, or
Database of Systematic Reviews. This is one researching nursing care. For more information
in a series of summaries of Cochrane Reviews on the CNCF, visit nursingcare.cochrane.org.
that we are publishing in collaboration with For more information on Cochrane Reviews,
the Cochrane Nursing Care Field (CNCF). The visit www.cochranelibrary.com.
CNCF aims to improve health outcomes through
increasing the use of the Cochrane Library and Postpartum depression is a serious mental
supporting Cochranes role by providing an evi- health disorder that affects approximately 5%
dence base for nurses and related health care of women after birth, with up to 20% of women

Abstract A 2014 Cochrane Review aimed to assess the effectiveness of antidepressant drugs compared with any other treat-
ment (psychological, psychosocial, or pharmacologic), placebo, or treatment as usual for postpartum depression. Rand-
omized controlled trials of women with depression with onset up to 6 months postpartum, which compared antidepressant
treatment with any other treatment, placebo, or treatment as usual were included in the study. A very limited body of evidence
was available for this review. Results of pooled estimates of responses showed that selective serotonin reuptake inhibitors were
significantly more effective than placebo in treating postpartum depression. http://dx.doi.org/10.1016/j.nwh.2017.04.007
Keywords antidepressants | Cochrane Review | maternal depression | postpartum depression | SSRI

nwhjournal.org 2017, AWHONN 155


experiencing elevated symptoms of depression Selection Criteria
Commentary in the first few months after birth (Stein et al., Randomized controlled trials of women with
2014). Postpartum depression can have short- depression with onset up to 6 months postpar-
and long-term effects on women, newborns, tum that compared antidepressant treatment
and families. (alone or in combination with another treat-
Currently, antidepressants are commonly ment) with any other treatment, placebo, or
used as the first treatment option for adults with treatment as usual were included in the study.
moderate to severe depression. However, there is
Data Collection and Analysis
Results of this review add to the
Two review authors independently extracted
evidence nurses can use in helping data from the trial reports. Missing information
women and their families make was requested from investigators wherever pos-
sible. Data were sought to enable an intention-
informed medical decisions to-treat analysis. Random-effects meta-analyses
were conducted to pool data where sufficient
little evidence on whether antidepressants are an comparable studies were identified.
effective and safe choice for the treatment of this
disorder in the postpartum period. Other treat- Results
ment options include psychosocial interventions Six trials with 596 participants were included in
such as peer support and psychological inter- this review. All studies had a randomized con-
ventions such as cognitive behavioral therapy. trolled parallel group design, with two con-
A systematic review was undertaken to eval- ducted in the United Kingdom, three in the
uate the effectiveness of treating postpartum United States, and one in Israel. Meta-analyses
depression with antidepressants compared with were performed to pool data on response and
the other treatment options (e.g., psychologi- remission from studies comparing antidepres-
cal or psychosocial interventions), placebo, or sants with placebo. No meta-analyses could be
treatment as usual. Results of this review add to conducted for other comparisons because of the
the evidence nurses can use in helping women small number of trials identified.
and their families make informed medical Four studies compared selective serotonin
decisions. reuptake inhibitors (SSRIs) with placebo (two
studies used sertraline, one used paroxetine,
Objective of the Review
and one used fluoxetine; there were 233 par-
The objective of this review (Molyneaux, How- ticipants in total). In two of these studies, the
ard, McGeown, Karia, & Trevillion, 2014) was experimental and placebo groups also received
to assess the effectiveness of antidepressant psychological therapy. Pooled risk ratios based
drugs compared with any other treatment (psy- on data from three of these studies (146 par-
chological, psychosocial, or pharmacologic), ticipants) showed that women randomized to
placebo, or treatment as usual for postpartum receive treatment with SSRIs had greater rates
depression. of response and remission than those random-
Rhoda Redulla, DNP,
ized to placebo (response: risk ratio = 1.43, 95%
RN-BC, is director of Intervention/Methods
confidence interval [1.01, 2.03]; remission: risk
the Magnet Program at The Cochrane Depression, Anxiety and ratio = 1.79, 95% confidence interval [1.08,
New York Presbyterian Neurosis Groups Specialized Register (i.e.,
Hospital/Weill Cornell
2.98]); the fourth study did not report data on
CCDANCTR) was searched through July 11, response or remission so was not included in the
Medical Center in New
2014. This register contains reports of relevant meta-analysis.
York, NY, and is a member
randomized controlled trials from the following One study (254 participants) compared anti-
of the Cochrane Nursing
bibliographic databases: The Cochrane Library depressant treatment with treatment as usual
Care Field. The author
reports no conflicts
(all years), MEDLINE (1950 to date), EMBASE (for the first 4 weeks) followed by listening vis-
of interest or relevant (1974 to date), and PsycINFO (1967 to date). its. The study found significantly greater rates of
financial relationships. The reviews authors also searched international improvement in the antidepressant group than
Address correspondence to: trial registries and contacted pharmaceutical treatment-as-usual group after the first 4 weeks
rhr9008@nyp.org. companies and experts in the field. but no difference between antidepressants and

156 Nursing for Womens Health Volume 21 Issue 3


inadequate evidence on whether the
benefits of antidepressants persist
beyond 8 weeks or whether they have
short- or long-term adverse effects on
breastfeeding infants.
Health care professionals who pro-
vide care to women with severe depres-
sion in the postpartum period will need
to draw on other evidence, including
trials among general adult populations
and observational studies of antide-
pressant safety when breastfeeding,
although the potential for confound-
ing in nonrandomized studies must be
considered.

Implications for
Nursing Practice
With the limitations imposed by the
available studies for review, clinicians
will need to individualize decisions
when considering antidepressants for
the postpartum population.
With the limitations imposed by the available Since the publication of the review
studies for review, clinicians will need to in 2014, new evidence may be available
to be used in clinical decision mak-
individualize decisions when considering
ing. There was a lack of information in
antidepressants for the postpartum population the studies in this review about infant
health outcomes after antidepressant
listening visits at the later follow-up. number of studies, which presented use during breastfeeding; therefore,
In addition, one study comparing ser- inadequate information on certain nurses and other clinicians should seek
traline with nortriptyline (a tricyclic outcomes, could be included. Pooled the most current evidence on this topic.
antidepressant) found no difference in estimates for response and remis- NWH
effectiveness (109 participants). sion found that SSRIs were signifi-
Adverse effects were experienced by cantly more effective than placebo
a substantial proportion of women, but for women with postpartum depres-
there was no evidence of a meaning- sion. However, the quality of evi-
ful difference in the overall number of dence contributing to this compari- References
adverse effects between treatment arms son was assessed as very low, owing to Molyneaux, E., Howard, L. M., McGe-
own, H. R., Karia, A. M., & Trevillion,
in any study. There were very limited the small sample size for this com-
Photo Monkey Business Images / thinkstockphotos.com

K. (2014). Antidepressant treatment


data on adverse effects experienced by parison (146 participants from three for postnatal depression. Cochrane
breastfed infants, with no long-term studies), the risk of bias in included Database of Systematic Reviews, 9,
follow-up. All but one of the studies studies, and the inclusion of one study CD002018. doi:10.1002/14651858
were assessed as being at high or uncer- where all participants in both study .CD002018.pub2
tain risk of attrition bias and selective arms additionally received psycho- Stein, A., Pearson, R. M., Goodman, S.
outcome reporting. In particular, one logical therapy. There was insuffi- H., Rapa, E., Rahman, A., McCallum,
M., . . . Pariante, C. M. (2014). Effects of
of the placebo-controlled studies had a cient evidence to conclude whether,
perinatal mental disorders on the fetus
drop-out rate of more than 50%. and for whom, antidepressant or psy- and child. The Lancet, 384, 18001819.
chologic/psychosocial treatments are doi:10.1016/S0140-6736(14)61277-0.
Conclusion of the Review more effective, or whether some anti-
A very limited body of evidence was depressants are more effective or bet-
available for this review. Only a small ter tolerated than others. There is also

June | July 2017 Nursing for Womens Health 157