Postnatal depression: drug treatments

Overview

General background | Focus of the review | Comments on evidence | Search and appraisal summary | Substantive changes at this update | Abstract | Cite as

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General background

A systematic review of studies from 1980 through March 2004 suggests that the point prevalence of major depressive disorder in predominantly high-income countries is about 5% in the first 3 months postpartum. When minor depression is included, it increases to 13%, with a period prevalence rate of 19%. These figures increase further in low-income countries. Although most women with postnatal depression recover within a few months, approximately 30% remain depressed after a year. The management of depression during this period is particularly important as it can have a significant impact on infant neurodevelopment. Furthermore, postnatal mental illness remains a leading cause of maternal mortality, although rates are lower in women postpartum than in women who have not had a baby.

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Focus of the review

In the UK, there is an absence of marketing authorisation for any psychotropic medication to be taken by women who are breastfeeding. This leaves the prescriber fully responsible for providing up-to-date information, so the woman can make an informed decision. Therefore, while we acknowledge that there are effective non-drug treatments for postnatal depression, the focus of this overview will be on pharmacological treatments.

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Comments on evidence

We found RCT evidence for two of our five interventions relative to placebo. No direct information from RCTs was found for fluoxetine versus placebo, paroxetine versus placebo, or St John's Wort versus placebo. One RCT reported no significant difference in the remission of depression following randomisation to sertraline and nortriptyline (a tricylic antidepressant). Despite the lack of good-quality evidence comparing SSRIs with placebo directly, SSRIs are likely to be beneficial for the treatment of postnatal depression based on evidence of their effectiveness in treating depressive disorders in general, and also in the treatment of premenstrual dysphoric disorder.

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Search and appraisal summary

The update literature search for this overview was carried out from the date of the last search, May 2008, to March 2014. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the overview, please see the Methods section. Searching of electronic databases retrieved 418 studies. After deduplication and removal of conference abstracts, 201 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 139 studies and the further review of 62 full publications. Of the 62 full articles evaluated, one systematic review was updated, and two systematic reviews and one RCT were added at this update

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Substantive changes at this update

Selective serotonin reuptake inhibitor (SSRI) antidepressants (fluoxetine, paroxetine, and sertraline) Two systematic reviews[27][28] and one RCT[30] added. Categorisation unchanged (likely to be beneficial).

Hormones One systematic review updated.[40] Categorisation unchanged (unknown effectiveness).

Abstract

INTRODUCTION: The differentiation between postnatal depression and other types of depression is often unclear, but there are treatment issues in nursing mothers that do not apply in other situations. The point prevalence of major depressive disorder in predominantly high-income countries is about 5% in the first 3 months postpartum. When minor depression is included, it increases to 13%, with a period prevalence rate of 19%. These figures increase further in low-income countries. METHODS AND OUTCOMES: We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of drug treatments for postnatal depression? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2014 (BMJ Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS: At this update, searching of electronic databases retrieved 418 studies. After deduplication and removal of conference abstracts, 201 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 139 studies and the further review of 62 full publications. Of the 62 full articles evaluated, one systematic review was updated, and two systematic reviews and one RCT were added at this update. We performed a GRADE evaluation for three PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for four interventions based on information about the effectiveness and safety of SSRI antidepressants, antidepressants other than SSRIs, hormones, and St John's Wort.

Cite as

Craig MC. Postnatal depression: drug treatments. Systematic review 1407. BMJ Clinical Evidence. . 2016 January. Accessed [date].

Latest guidelines

Latest citations

Effectiveness of Psychological Interventions for Postnatal Depression in Primary Care: A Meta-Analysis. ( 10 January 2017 )

A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression. ( 06 July 2016 )