Clinical Evidence Concise
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Am Fam Physician. 2005 Oct 1;72(7):1294-1296.
This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The evidence is available at http://www.clinicalevidence.com/ceweb/conditions/pac/1407/1407.jsp.
What are the effects of drug treatments?
LIKELY TO BE BENEFICIAL
Antidepressants (Fluoxetine [Included on the Evidence of Its Effectiveness in the Treatment of Depression in General])
One small randomized controlled trial (RCT) showed limited evidence that fluoxetine plus one or six cognitive behavior therapy sessions may improve postnatal depression at four and 12 weeks compared with placebo plus one or six cognitive behavior therapy sessions. The RCT had methodologic weaknesses, a high withdrawal rate, and it excluded breastfeeding women. However, fluoxetine is known to be effective in managing depression in the general population and therefore is likely beneficial for the management of postnatal depression.
Antidepressants Other Than Fluoxetine
We found no RCTs on the effects of other antidepressants in women with postnatal depression, and we found no RCTs that compared other antidepressants with psychological treatments.
One small RCT that included women with severe postnatal depression showed that estrogen treatment improved postnatal depression at three and six months compared with placebo.
What are the effects of nondrug treatments?
LIKELY TO BE BENEFICIAL
Limited evidence from two RCTs suggested that, in the short term (immediately after treatment), non-directive counseling improved postnatal depression compared with routine primary care. One RCT, with follow-up beyond 12 weeks, showed no clear long-term benefits (nine months to five years postpartum) from nondirective counseling compared with routine primary care, individual cognitive behavior therapy, or psychodynamic therapy.
Cognitive Behavior Therapy (Individual)
One small RCT showed limited evidence that individual cognitive behavior therapy and ideal standard care improved depressive symptoms, but there was no significant difference between the two interventions. Limited evidence from one RCT suggested that individual cognitive behavior therapy may improve postnatal depression in the short term compared with routine primary care. The RCT found no clear long-term benefits from individual cognitive behavior therapy compared with routine primary care, nondirective counseling, or psychodynamic therapy.
One RCT showed that interpersonal psychotherapy improved postnatal depression compared with waiting list controls at 12 weeks.
One RCT provided limited evidence that psychodynamic therapy may improve postnatal depression in the short term compared with routine primary care. The RCT showed no clear long-term benefits from psychodynamic therapy compared with routine primary care, non-directive counseling, or cognitive behavior therapy.
We found no RCTs on the effects of light therapy.
Cognitive Behavior Therapy (Group)
One small RCT that included women with a high level of depressive symptoms on screening showed that group cognitive behavior therapy improved symptoms at six months compared with routine primary care.
Psychoeducation with Partner
One small RCT showed that psychoeducation with partners reduced patients’ depression scores and partners’ psychiatric morbidity at 10 weeks compared with psychoeducation without partners.
Mother-Infant Interaction Coaching
One RCT showed that mother-infant interaction coaching had no significant effect on maternal depression scores compared with usual treatment, but it improved maternal responsiveness to the infant within 10 weeks of starting treatment.
Telephone-Based Peer Support (Mother-to-Mother)
One small RCT showed that telephone-based peer support reduced depression scores compared with usual treatment at four months.
Postnatal depression is broadly defined as nonpsychotic depression occurring during the first six months postpartum. Puerperal mental disorders have only recently been categorized separately in psychiatric classifications, but the International Classification of Diseases, 10th ed. (ICD-10)1 and the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) require certain qualifications that limit their use. For example, ICD-10 categorizes postpartum mental disorders as puerperal, but only if they cannot otherwise be classified. DSM-IV allows “postpartum onset” to be specified for mood disorders starting within four weeks postpartum.2 In clinical practice and research, the broader definition above often is used, because whether or not postnatal depression is truly distinct from depression in general, depression in the postpartum period raises treatment issues for the nursing mother and has implications for the developing infant (see prognosis section). Postnatal depression symptoms are similar to depression at other times of life. However, in addition to negative mood, sleep disturbance, change in appetite, diurnal variation in mood, poor concentration, and irritability, women with postnatal depression also experience guilt about their inability to care for their new baby. In many countries, physicians screen for postnatal depression using the Edinburgh Postnatal Depression Scale,3,4 which identifies depressive symptoms.
The incidence of depression in women postpartum is similar to depression in women generally. However, the incidence of depression in the first month after childbirth is three times the average monthly incidence in nonchildbearing women.5 Studies across different cultures have shown consistent incidence of postnatal depression (10 to 15 percent),6 with higher rates in teenage mothers. A meta-analysis of studies, mainly based in developed countries, found the incidence of postnatal depression to be 12 to 13 percent.7
Four systematic reviews have identified the following risk factors for postnatal depression: past history of psychopathology, including postnatal depression; low social support; poor marital relationships; and recent life events.7–10 Recent studies from India and China also suggest that spousal disappointment with the sex of the newborn child, particularly if the child is a girl, is associated with postnatal depression.10 The mother’s reaction to the sex of the baby also may be a risk factor within some cultural groups.
Most episodes of postnatal depression resolve spontaneously within three to six months,11 but about one out of four mothers is still depressed on the child’s first birthday.12 In developed countries, suicide is now the main cause of maternal death in the first year post-partum,13 but the suicide rate is lower than in age-matched nonpostpartum women.14 Postnatal depression also is associated with reduced likelihood of secure attachment15; deficits in maternal-infant interactions16; and impaired cognitive and emotional development of the child, particularly in boys living in areas of socioeconomic deprivation.16–18 These associations remain significant even after controlling for subsequent episodes of depression in the mother.
search date: January 2004
Adapted with permission from Howard L. Postnatal depression. Clin Evid Concise 2005;13:410–2.
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2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. New York: American Psychiatric Association, 1994.
3. Murray L, Carothers AD. The validation of the Edinburgh Postnatal Depression Scale on a community sample. Br J Psychiatry. 1990;157:288–90.
4. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–6.
5. Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry. 1993;163:27–31.
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8. Beck CT. A meta-analysis of predictors of postpartum depression. Nurs Res. 1996;45:297–303.
9. Wilson LM, Reid AJ, Midmer DK, et al. Antenatal psychosocial risk factors associated with adverse postnatal family outcomes. CMAJ. 1996;154:785–99.
10. Robertson E, Grace S, Wallington T, et al. Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiatry. 2004;26:289–95.
11. Cooper PJ, Murray L. Course and recurrence of postnatal depression. Evidence for the specificity of the diagnostic concept. Br J Psychiatry. 1995;166:191–5.
12. Kumar R, Robson KM. A prospective study of emotional disorders in childbearing women. Br J Psychiatry. 1984;144:35–47.
13. The fifth report of the confidential enquiries into maternal deaths in the United Kingdom. London: Royal College of Obstetricians and Gynaecologists, 2001.
14. Appleby L. Suicide during pregnancy and in the first postnatal year. BMJ. 1991;302:137–40.
15. Martins C, Gaffan EA. Effects of early maternal depression on patterns of infant–mother attachment: a meta-analytic investigation. J Child Psychol Psychiatry. 2000;41:737–46.
16. Murray L, Cooper PJ. The impact of postpartum depression on child development. Int Rev Psychiatry. 1996;8:55–63.
17. Carter AS, Garrity-Rokous EF, Chazan-Cohen R, et al. Maternal depression and comorbidity: Predicting early parenting, attachment security, and toddler social-emotional problems and competencies. J Am Acad Child Adolesc Psychiatry. 2001;40:18–26.
18. Hay DF, Pawlby S, Sharp D, et al. Intellectual problems shown by 11-year-old children whose mothers had postnatal depression. J Child Psychol Psychiatry. 2001;42:871–89.
This is one in a series of chapters excerpted fromClinical Evidence Concise, published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom.Clinical Evidence Concise is published in print twice a year and is updated monthly online. Each topic is revised every 12 months, and subscribers should view the most up-to-date version at http://www.clinicalevidence.com. If you are interested in contributing toClinical Evidence, send an e-mail to CEcommissioning@bmjgroup.com. This series is part of the AFP.See “Clinical Quiz” on page 1167.
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