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


Commentary
Results of this review add to the
evidence nurses can use in helping
Rhoda Redulla, DNP,
RN-BC, is director of
the Magnet Program at
New York Presbyterian
Hospital/Weill Cornell
Medical Center in New
York, NY, and is a member
of the Cochrane Nursing
Care Field. The author
reports no conflicts
of interest or relevant
financial relationships.
Address correspondence to:
rhr9008@nyp.org.
156 Nursing for Womens Health Volume 21
experiencing elevated symptoms of depression
in the first few months after birth (Stein et al.,
2014). Postpartum depression can have short-
and long-term effects on women, newborns,
and families.
Currently, antidepressants are commonly
used as the first treatment option for adults with
moderate to severe depression. However, there is
women and their families make
informed medical decisions
little evidence on whether antidepressants are an
effective and safe choice for the treatment of this
disorder in the postpartum period. Other treat-
ment options include psychosocial interventions
such as peer support and psychological inter-
ventions such as cognitive behavioral therapy.
A systematic review was undertaken to eval-
uate the effectiveness of treating postpartum
depression with antidepressants compared with
the other treatment options (e.g., psychologi-
cal or psychosocial interventions), placebo, or
treatment as usual. Results of this review add to
the evidence nurses can use in helping women
and their families make informed medical
decisions.
Objective of the Review
The objective of this review (Molyneaux, How-
ard, McGeown, Karia, & Trevillion, 2014) was
to assess the effectiveness of antidepressant
drugs compared with any other treatment (psy-
chological, psychosocial, or pharmacologic),
placebo, or treatment as usual for postpartum
depression.
Intervention/Methods
The Cochrane Depression, Anxiety and
Neurosis Groups Specialized Register (i.e.,
CCDANCTR) was searched through July 11,
2014. This register contains reports of relevant
randomized controlled trials from the following
bibliographic databases: The Cochrane Library
(all years), MEDLINE (1950 to date), EMBASE
(1974 to date), and PsycINFO (1967 to date).
The reviews authors also searched international
trial registries and contacted pharmaceutical
companies and experts in the field.
Selection Criteria
Randomized controlled trials of women with
depression with onset up to 6 months postpar-
tum that compared antidepressant treatment
(alone or in combination with another treat-
ment) with any other treatment, placebo, or
treatment as usual were included in the study.
Data Collection and Analysis
Two review authors independently extracted
data from the trial reports. Missing information
was requested from investigators wherever pos-
sible. Data were sought to enable an intention-
to-treat analysis. Random-effects meta-analyses
were conducted to pool data where sufficient
comparable studies were identified.
Results
Six trials with 596 participants were included in
this review. All studies had a randomized con-
trolled parallel group design, with two con-
ducted in the United Kingdom, three in the
United States, and one in Israel. Meta-analyses
were performed to pool data on response and
remission from studies comparing antidepres-
sants with placebo. No meta-analyses could be
conducted for other comparisons because of the
small number of trials identified.
Four studies compared selective serotonin
reuptake inhibitors (SSRIs) with placebo (two
studies used sertraline, one used paroxetine,
and one used fluoxetine; there were 233 par-
ticipants in total). In two of these studies, the
experimental and placebo groups also received
psychological therapy. Pooled risk ratios based
on data from three of these studies (146 par-
ticipants) showed that women randomized to
receive treatment with SSRIs had greater rates
of response and remission than those random-
ized to placebo (response: risk ratio = 1.43, 95%
confidence interval [1.01, 2.03]; remission: risk
ratio = 1.79, 95% confidence interval [1.08,
2.98]); the fourth study did not report data on
response or remission so was not included in the
meta-analysis.
One study (254 participants) compared anti-
depressant treatment with treatment as usual
(for the first 4 weeks) followed by listening vis-
its. The study found significantly greater rates of
improvement in the antidepressant group than
treatment-as-usual group after the first 4 weeks
but no difference between antidepressants and
Issue 3

With the limitations imposed by the available
studies for review, clinicians will need to
individualize decisions when considering
antidepressants for the postpartum population
listening visits at the later follow-up.
In addition, one study comparing ser-
traline with nortriptyline (a tricyclic
antidepressant) found no difference in
effectiveness (109 participants).
Adverse effects were experienced by
a substantial proportion of women, but
there was no evidence of a meaning-
ful difference in the overall number of
adverse effects between treatment arms
in any study. There were very limited
Photo Monkey Business Images / thinkstockphotos.com
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 uncer-
tain risk of attrition bias and selective
outcome reporting. In particular, one
of the placebo-controlled studies had a
drop-out rate of more than 50%.
Conclusion of the Review
A very limited body of evidence was
available for this review. Only a small
June | July 2017 Nursing for Womens Health
number of studies, which presented
inadequate information on certain
outcomes, could be included. Pooled
estimates for response and remis-
sion found that SSRIs were signifi-
cantly more effective than placebo
for women with postpartum depres-
sion. However, the quality of evi-
dence contributing to this compari-
son was assessed as very low, owing to
the small sample size for this com-
parison (146 participants from three
studies), the risk of bias in included
studies, and the inclusion of one study
where all participants in both study
arms additionally received psycho-
logical therapy. There was insuffi-
cient evidence to conclude whether,
and for whom, antidepressant or psy-
chologic/psychosocial treatments are
more effective, or whether some anti-
depressants are more effective or bet-
ter tolerated than others. There is also
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.
Since the publication of the review
in 2014, new evidence may be available
to be used in clinical decision mak-
ing. There was a lack of information in
the studies in this review about infant
health outcomes after antidepressant
use during breastfeeding; therefore,
nurses and other clinicians should seek
the most current evidence on this topic.
NWH
References
Molyneaux, E., Howard, L. M., McGe-
own, H. R., Karia, A. M., & Trevillion,
K. (2014). Antidepressant treatment
for postnatal depression. Cochrane
Database of Systematic Reviews, 9,
CD002018. doi:10.1002/14651858
.CD002018.pub2
Stein, A., Pearson, R. M., Goodman, S.
H., Rapa, E., Rahman, A., McCallum,
M., . . . Pariante, C. M. (2014). Effects of
perinatal mental disorders on the fetus
and child. The Lancet, 384, 18001819.
doi:10.1016/S0140-6736(14)61277-0.
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