Antidepressant treatment for postnatal depression.

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 METHODS: 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. 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.

Maternal mental health and infant emotional reactivity: a 20-year two-cohort study of preconception and perinatal exposures.

BACKGROUND: Maternal mental health during pregnancy and postpartum predicts later emotional and behavioural problems in children. Even though most perinatal mental health problems begin before pregnancy, the consequences of preconception maternal mental health for children's early emotional development have not been prospectively studied. METHODS: We used data from two prospective Australian intergenerational cohorts, with 756 women assessed repeatedly for mental health problems before pregnancy between age 13 and 29 years, and during pregnancy and at 1 year postpartum for 1231 subsequent pregnancies. Offspring infant emotional reactivity, an early indicator of differential sensitivity denoting increased risk of emotional problems under adversity, was assessed at 1 year postpartum. RESULTS: Thirty-seven percent of infants born to mothers with persistent preconception mental health problems were categorised as high in emotional reactivity, compared to 23% born to mothers without preconception history (adjusted OR 2.1, 95% CI 1.4-3.1). Ante- and postnatal maternal depressive symptoms were similarly associated with infant emotional reactivity, but these perinatal associations reduced somewhat after adjustment for prior exposure. Causal mediation analysis further showed that 88% of the preconception risk was a direct effect, not mediated by perinatal exposure. CONCLUSIONS: Maternal preconception mental health problems predict infant emotional reactivity, independently of maternal perinatal mental health; while associations between perinatal depressive symptoms and infant reactivity are partially explained by prior exposure. Findings suggest that processes shaping early vulnerability for later mental disorders arise well before conception. There is an emerging case for expanding developmental theories and trialling preventive interventions in the years before pregnancy.

Disordered personality traits and psychiatric morbidity in pregnancy: a population-based study.

This study aims to investigate the characteristics and mental health status of pregnant women with disordered personality traits. A cross-sectional study of a stratified sample of 545 women attending antenatal booking at a South London maternity service was conducted. Disordered personality traits were assessed using the Standardised Assessment of Personality-Abbreviated Scale (SAPAS). Mental disorders were assessed using the Structured Clinical Interview DSM-IV (SCID). Logistic regression was used to model associations, adjusting for confounders. Complete SAPAS data were collected for over 99% of women (n = 541). The weighted prevalence of elevated disordered personality traits (SAPAS ≥ 3) was 16.2% (95% CI 12.6-20.5). Women with elevated disordered personality traits were younger, less likely to live alone and more likely to report living in insecure accommodation. Among women with elevated disordered personality traits, the most common mental disorders were anxiety disorders (31.4%) and depressive disorders (17.6%). Each extra item endorsed on the SAPAS was associated with an 82% higher odds of meeting criteria for an Axis I mental disorder (adjusted OR 1.82 (1.42-2.33); p < 0.001). Women with elevated disordered personality traits were at significantly increased risk of experiencing thoughts of self-harm (adjusted OR 2.12 (1.33-3.40); p = 0.002). Pregnant women with disordered personality traits are a particularly vulnerable population, with multiple psychosocial problems that are likely to require tailored support to ameliorate future health risks for mother and baby.

Maternal personality traits, antenatal depressive symptoms and the postpartum mother-infant relationship: a prospective observational study.

PURPOSE: Maternal depression has been associated with bonding difficulties and lower maternal sensitivity in observed mother-infant interactions. However, little research has examined the impact of disordered personality traits in mothers on these outcomes. We investigated the association between disordered personality traits in mothers measured during pregnancy and postnatal (a) self-reported bonding with infant; (b) observational mother-infant interactions. METHODS: Five hundred fifty-six women were recruited during early pregnancy and subsequently followed up at mid-pregnancy (approximately 28 weeks' gestation) and when infants were aged approximately 3 months (n = 459). During early pregnancy, data were collected on disordered personality traits (using the Standardised Assessment of Personality Abbreviated Scale) and depressive symptoms (using the Edinburgh Postnatal Depression Scale). At 3 months postpartum, self-reported perceived bonding (using the Postpartum Bonding Questionnaire) were collected. A sub-sample of women additionally provided observational mother-infant interaction data (n = 206) (coded using the Child-Adult Relationship Experimental Index). RESULTS: Higher disordered personality traits was not associated with maternal perceptions of bonding impairment, but was associated with reduced maternal sensitivity during observational mother-infant interactions [adjusted for age, education, having older children, substance misuse prior to pregnancy, infant sex and gestational age: coefficient = - 0.28, 95% CI = - 0.56 to - 0.00, p < 0.05]. After adjusting for depressive symptoms, the association was attenuated [coefficient = - 0.19, 95% CI = - 0.48 to 0.11, p = 0.217]. CONCLUSIONS: Mothers with disordered personality traits did not perceive themselves as having bonding impairments with their infants but were less sensitive during observed interactions, though depressive symptoms attenuated this relationship. Both depression and disordered personality traits need to be addressed to optimize mother-infant interactions.

Is There an Association Between Diet, Physical Activity and Depressive Symptoms in the Perinatal Period? An Analysis of the UPBEAT Cohort of Obese Pregnant Women.

INTRODUCTION: Depression is a common morbidity of the perinatal period (during pregnancy and up to one year postpartum). There is evidence for an association between diet and physical activity, and depression in the non-pregnant population but this association has been relatively less explored during the perinatal period; particularly poorly understood is the relationship between specific dietary components and depression. The aim of this study was to explore the association between glycaemic load, saturated fat intake and physical activity and depressive symptoms in a high-risk population of obese pregnant women. METHODS: In a cohort of 1522 women participating in the UPBEAT trial, physical activity, glycaemic load and saturated fat intake were used as predictors of depressive symptoms measured using the Edinburgh Postnatal Depression Scale (EPDS). Measures taken in early pregnancy were used in linear and logistic regression models. Repeated measures at three points during pregnancy and at six months postpartum were utilised in multilevel mixed effects models. Multiple imputation was used to account for missing data. RESULTS: Increased glycaemic load was associated with small increases in levels of depressive symptoms across the perinatal period (adjusted beta coefficient 0.01; 95% CI 0.01,0.02). There was no evidence for an association between reduced physical activity and increased saturated fat intake and increased levels of depressive symptoms. CONCLUSIONS: Glycaemic load may be a useful focus for interventions aiming to optimise the mental health of obese women in the perinatal period.

Correction to: Is There an Association Between Diet, Physical Activity and Depressive Symptoms in the Perinatal Period? An Analysis of the UPBEAT Cohort of Obese Pregnant Women.

The original version of this article contained an error in one of the author name. The co-author name was published as "Angela Flynn", instead it should be "Angela C. Flynn".

Hormonal Contraceptive Use and Risk of Attempted and Completed Suicide: a Systematic Review and Narrative Synthesis.

Despite its widespread use, there is conflicting evidence on the association between hormonal contraception and the risk of suicide among women. This review seeks to identify, appraise and synthesize all studies on the association between hormonal contraceptive use and attempted or completed suicide. A systematic review was performed in accordance with PRISMA guidelines. Relevant citations were identified from three bibliographic databases (MEDLINE, EMBASE, and PsycInfo). Cross-sectional, cohort and case control studies were included. Quality of studies was assessed with validated tools, and a narrative synthesis was conducted to summarize study findings. Nine studies reporting on six samples (n = 683,198) were included. Three studies reported data for the association between hormonal contraceptive use and suicide attempts, and five studies reported data on completed suicides. Both protective and adverse associations between hormonal contraception and risk of suicide were identified. The evidence of the association was weakened by low to moderate methodological quality of studies. Our review found there was substantial variability in the relationships reported between hormonal contraceptive use and suicide risk. Going forward, researchers investigating this topic are encouraged to use population-based samples to take efforts to control for important confounding variables. Additional research is also needed to investigate the effects of more recent hormonal contraceptive methods on suicide risk.

Pre-conception self-harm, maternal mental health and mother-infant bonding problems: a 20-year prospective cohort study.

BACKGROUND: Self-harm in young people is associated with later problems in social and emotional development. However, it is unknown whether self-harm in young women continues to be a marker of vulnerability on becoming a parent. This study prospectively describes the associations between pre-conception self-harm, maternal depressive symptoms and mother-infant bonding problems. METHODS: The Victorian Intergenerational Health Cohort Study (VIHCS) is a follow-up to the Victorian Adolescent Health Cohort Study (VAHCS) in Australia. Socio-demographic and health variables were assessed at 10 time-points (waves) from ages 14 to 35, including self-reported self-harm at waves 3-9. VIHCS enrolment began in 2006 (when participants were aged 28-29 years), by contacting VAHCS women every 6 months to identify pregnancies over a 7-year period. Perinatal depressive symptoms were assessed with the Edinburgh Postnatal Depression Scale during the third trimester, and 2 and 12 months postpartum. Mother-infant bonding problems were assessed with the Postpartum Bonding Questionnaire at 2 and 12 months postpartum. RESULTS: Five hundred sixty-four pregnancies from 384 women were included. One in 10 women (9.7%) reported pre-conception self-harm. Women who reported self-harming in young adulthood (ages 20-29) reported higher levels of perinatal depressive symptoms and mother-infant bonding problems at all perinatal time points [perinatal depressive symptoms adjusted ß = 5.40, 95% confidence interval (CI) 3.42-7.39; mother-infant bonding problems adjusted ß = 7.51, 95% CI 3.09-11.92]. There was no evidence that self-harm in adolescence (ages 15-17) was associated with either perinatal outcome. CONCLUSIONS: Self-harm during young adulthood may be an indicator of future vulnerability to perinatal mental health and mother-infant bonding problems.

Antidepressants for preventing postnatal depression.

BACKGROUND: Depression is common in the postnatal period and can lead to adverse effects on the infant and wider family, in addition to the morbidity for the mother. It is not clear whether antidepressants are effective for the prevention of postnatal depression and little is known about possible adverse effects for the mother and infant, particularly during breastfeeding. This is an update of a Cochrane Review last published in 2005. OBJECTIVES: To assess the effectiveness of antidepressant medication for the prevention of postnatal depression, in comparison with any other treatment, placebo or standard care. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR ‒ both Studies and References), CENTRAL (Wiley), MEDLINE (OVID), Embase (OVID), PsycINFO (OVID), on 13 February 2018. We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov on 13 February 2018 to identify any additional unpublished or ongoing studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) of initiation of antidepressants (alone or in combination with another treatment), compared with any other treatment, placebo or standard care for the prevention of postnatal depression among women who were either pregnant or had given birth in the previous six weeks and were not currently depressed at baseline. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We requested missing information from investigators wherever possible and sought data to allow intention-to-treat analyses. MAIN RESULTS: Two trials including a total of 81 participants fulfilled the inclusion criteria for this review. All participants in both studies had a history of postnatal depression and were not taking antidepressant medication at baseline. Both trials were conducted by the same research group. Risk of bias was low or unclear in most domains for both studies. We were unable to perform a meta-analysis due to the small number of studies.One study compared nortriptyline with placebo and did not find any evidence that nortriptyline was effective in preventing postnatal depression. In this study, 23% (6/26) of women who took nortriptyline and 24% (6/25) of women who took placebo experienced postnatal depression (RR 0.96, 95% CI 0.36 to 2.59, very low quality evidence) in the first 17 weeks postpartum. One woman taking nortriptyline developed mania; and one side effect, constipation, was more common among women taking nortriptyline than those taking placebo.The second study compared sertraline with placebo. In this study, 7% (1/14) of women who took sertraline developed postnatal depression in the first 17 weeks postpartum compared with 50% (4/8) of women who took placebo. It is uncertain whether sertraline reduces the risk of postnatal depression (RR 0.14, 95% CI 0.02 to 1.07, very low quality evidence). One woman taking sertraline had a hypomanic episode. Two side effects (dizziness and drowsiness) were more common among women taking sertraline than women taking placebo.Conclusions are limited by the small number of studies, small sample sizes and incomplete outcome data due to study drop-out which may have led to bias in the results. We have assessed the certainty of the evidence as very low, based on the GRADE system. No data were available on secondary outcomes of interest including child development, the mother‒infant relationship, breastfeeding, maternal daily functioning, family relationships or maternal satisfaction. AUTHORS' CONCLUSIONS: Due to the limitations of the current evidence base, such as the low statistical power of the included studies, it is not possible to draw any clear conclusions about the effectiveness of antidepressants for the prevention of postnatal depression. It is striking that no new eligible trials have been completed in the period of over a decade since the last published version of this review. Larger trials are needed which include comparisons of antidepressant drugs with other prophylactic treatments (e.g. psychological interventions), and examine adverse effects for the fetus or infant. Future reviews in this area may benefit from broadening their focus to examine the effectiveness of antidepressants for the prevention of perinatal (i.e. antenatal or postnatal) depression, which could include studies comparing antidepressant discontinuation with continuation for the prevention of relapse of depression during pregnancy and the postnatal period.

Do elevated symptoms of depression predict adherence and outcomes in the UPBEAT randomised controlled trial of a lifestyle intervention for obese pregnant women?

BACKGROUND: Lifestyle interventions for obese pregnant women have been widely researched but little is known about predictors of low adherence or poor outcomes. This study evaluated the prospective associations between elevated symptoms of antenatal depression and gestational diabetes, adherence and gestational weight gain in a large RCT of a behavioural intervention for obese pregnant women. The effect of the intervention on symptoms of depression at follow-up was also examined. METHODS: The UPBEAT RCT randomised 1555 obese pregnant women to receive a dietary and physical activity lifestyle intervention or standard care. Symptoms of antenatal depression were assessed with the Edinburgh Postnatal Depression Scale at baseline (15+ 0-18+ 6 weeks' gestation) and follow-up (27+ 0-28+ 6 weeks' gestation). Gestational diabetes was assessed with an oral glucose tolerance test at 27+ 0-28+ 6 weeks' gestation. Adherence was pre-defined as receiving at least 5 of 8 intervention sessions. Gestational weight gain was calculated as the difference between pre-pregnancy weight (estimated as measured baseline weight minus 1.25 kg) and last measured weight at 34+ 0-36+ 0 weeks' gestation. Due to substantial missing data in certain variables, multiple imputation was used to impute missing data. Women who were no longer pregnant at 27+ 0-28+ 6 weeks' gestation were excluded from the sample for these analyses. RESULTS: One thousand five-hundered twenty-six women were included in these analyses following multiple imputation; 797 (52.2%) had complete data. 13.4% had elevated symptoms of antenatal depression at baseline. There was no evidence for associations between antenatal depression status and gestational diabetes (adjusted OR 0.80, 95%CI 0.52 to 1.22, p = 0.30), adherence (adjusted OR 1.16, 95%CI 0.63 to 2.15, p = 0.63) or gestational weight gain (adjusted regression coefficient 0.52, 95%CI -0.26 to 1.29, p = 0.19). The intervention was not associated with change in depressive symptoms at follow-up (regression coefficient 0.003, 95%CI -0.49 to 0.49, p = 0.99). Similar results were obtained in complete case analyses. CONCLUSIONS: Elevated symptoms of antenatal depression did not predict gestational diabetes, adherence or gestational weight gain in this large RCT of a lifestyle intervention for obese pregnant women. The intervention also did not influence symptoms of depression at follow-up. Obese pregnant women with elevated symptoms of depression should not be excluded from lifestyle interventions. TRIAL REGISTRATION: ISRCTN89971375 . Registered 28 November 2008.

Obesity, antenatal depression, diet and gestational weight gain in a population cohort study.

PURPOSE: The aims of this paper are to examine: (1) the relationship between high pre-pregnancy BMI and antenatal depression; (2) whether BMI and antenatal depression interact to predict diet and gestational weight gain (GWG). METHODS: Data came from the Avon Longitudinal Study of Parents and Children (ALSPAC). Underweight women were excluded. Pre-pregnancy BMI was self-reported and antenatal depression was assessed using the Edinburgh Postnatal Depression Scale at 18 and 32 weeks' gestation to identify persistently elevated depressive symptoms (EPDS>12). Dietary patterns were calculated from food frequency questionnaires at 32 weeks' gestation. GWG was categorised using the USA Institute of Medicine guidelines. RESULTS: This study included 13,314 pregnant women. Obese women had significantly higher odds of antenatal depression than normal weight controls after adjusting for socio-demographics and health behaviours (aOR 1.39, 95%CI 1.05-1.84). Every unit increase in pre-pregnancy BMI was associated with approximately 3% higher odds of antenatal depression (aOR 1.03, 95%CI 1.01-1.05). Antenatal depression was not meaningfully associated with dietary patterns after adjusting for confounders and was not associated with inadequate or excessive GWG. There was no evidence for an interaction of depression and BMI on either diet or GWG. CONCLUSIONS: Healthcare professionals should be aware of the dose-response relationship between high pre-pregnancy BMI and antenatal depression.

Non-psychotic mental disorders in the perinatal period.

Mental disorders are among the most common morbidities of pregnancy and the postnatal period, and can have adverse effects on the mother, her child, and family. This Series paper summarises the evidence about epidemiology, risk factors, identification, and interventions for non-psychotic mental disorders. Although the phenomenology and risk factors for perinatal mental disorders are largely similar to those for the disorders at other times, treatment considerations differ during pregnancy and breastfeeding. Most randomised controlled trials have examined psychosocial and psychological interventions for postnatal depression, with evidence for effectiveness in treating and preventing the disorder. Few high-quality studies exist on the effectiveness or safety of pharmacological treatments in the perinatal period, despite quite high prescription rates. General principles of prescribing of drugs in the perinatal period are provided, but individual risk-benefit analyses are needed for decisions about treatment.

Antidepressant treatment for postnatal depression.

CLINICAL QUESTION: Are antidepressants associated with improved outcomes for postnatal depression? BOTTOM LINE: Compared with placebo, selective serotonin reuptake inhibitors (SSRIs) are associated with better response and remission rates for postnatal depression. However, few studies included women with severe depression or suicidal ideation. There are insufficient data to conclude whether antidepressants are associated with better outcomes than psychological interventions.

Antidepressant treatment for postnatal depression.

BACKGROUND: Postnatal depression is a common disorder that can have adverse short- and long-term effects on maternal morbidity, the new infant and the family as a whole. Treatment is often largely by social support and psychological interventions. It is not known whether antidepressants are an effective and safe choice for treatment of this disorder. This review was undertaken to evaluate the effectiveness of different antidepressants and to compare their effectiveness with other forms of treatment, placebo or treatment as usual. It is an update of a review first published in 2001. OBJECTIVES: To assess the effectiveness of antidepressant drugs in comparison with any other treatment (psychological, psychosocial or pharmacological), placebo or treatment as usual for postnatal depression. SEARCH METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Group's Specialized Register (CCDANCTR) to 11 July 2014. This register contains reports of relevant randomised controlled trials (RCTs) from the following bibliographic databases: The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE, (1974 to date) and PsycINFO (1967 to date). We also searched international trial registries and contacted pharmaceutical companies and experts in the field. SELECTION CRITERIA: We included RCTs of women with depression with onset up to six 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 trial reports. We requested missing information from investigators wherever possible. We sought data to allow an intention-to-treat analysis. Random effects meta-analyses were conducted to pool data where sufficient comparable studies were identified. MAIN RESULTS: We included six trials with 596 participants in this review. All studies had a randomised controlled parallel group design, with two conducted in the UK, three in the US and one in Israel. Meta-analyses were performed to pool data on response and remission from studies comparing antidepressants with placebo. No meta-analyses could be conducted for other comparisons due to the small number of trials identified.Four studies compared selective serotonin reuptake inhibitors (SSRIs) with placebo (two using sertraline, one using paroxetine and one using fluoxetine; 233 participants in total). In two of these studies both the experimental and placebo groups also received psychological therapy. Pooled risk ratios based on data from three of these studies (146 participants) showed that women randomised to SSRIs had higher rates of response and remission than those randomised to placebo (response: RR 1.43, 95% CI 1.01 to 2.03; remission: RR 1.79, 95% CI 1.08 to 2.98); the fourth study did not report data on response or remission.One study (254 participants) compared antidepressant treatment with treatment as usual (for the first four weeks) followed by listening visits. The study found significantly higher rates of improvement in the antidepressant group than treatment-as-usual group after the first four weeks, but no difference between antidepressants and listening visits at the later follow-up. In addition, one study comparing sertraline with nortriptyline (a tricyclic antidepressant) found no difference in effectiveness (109 participants).Side effects were experienced by a substantial proportion of women, but there was no evidence of a meaningful difference in the number of adverse effects between treatment arms in any study. There were very limited 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 uncertain risk of attrition bias and selective outcome reporting. In particular, one of the placebo-controlled studies had over 50% drop-out. AUTHORS' CONCLUSIONS: The evidence base for this review was very limited, with a small number of studies and little information on a number of important outcomes, particularly regarding potential effects on the child. Risk of bias, for example from high attrition rates, as well as low representativeness of participants (e.g. exclusion of women with severe or chronic depression in several trials) also limit the conclusions that can be drawn.Pooled estimates for response and remission found that SSRIs were significantly more effective than placebo for women with postnatal depression. However the quality of evidence contributing to this comparison was assessed as very low owing to the small sample size for this comparison (146 participants from three studies), the risk of bias in included studes and the inclusion of one study where all participants in both study arms additionally received psychological therapy. There was insufficient evidence to conclude whether, and for whom, antidepressant or psychological/psychosocial treatments are more effective, or whether some antidepressants are more effective or better tolerated than others. There is also inadequate evidence on whether the benefits of antidepressants persist beyond eight weeks or whether they have short- or long-term adverse effects on breastfeeding infants.Professionals treating women with severe depression in the postnatal period will need to draw on other evidence, including trials among general adult populations and observational studies of antidepressant safety when breastfeeding (although the potential for confounding in non-randomised studies must be considered). More RCTs are needed with larger sample sizes and longer follow-up, including assessment of the impact on the child and safety of breastfeeding. Further larger-scale trials comparing antidepressants with alternative treatment modalities are also required.

The plasticity of adolescent cognitions: data from a novel cognitive bias modification training task.

Many adult anxiety problems emerge in adolescence. Investigating how adolescent anxiety arises and abates is critical for understanding and preventing adult psychiatric problems. Drawing threat interpretations from ambiguous material is linked to adolescent anxiety but little research has clarified the causal nature of this relationship. Work in adults using Cognitive Bias Modification of Interpretations (CBM-I) training show that manipulating negative interpretational style alters negative affect. Conversely, 'boosting' positive interpretations improves affect. Here, we extend CBM-I investigations to adolescents. Thirty-nine adolescents (13-18 years), varying in trait anxiety and self-efficacy, were randomly allocated to receive positive or negative training. Training-congruent differences emerged for subsequent interpretation style. Induced negative biases predicted a decline in positive affect in low self-efficacious adolescents only. Tentatively, our data suggest that cognitive biases predict adolescent affective symptoms in vulnerable individuals. The acquisition of positive cognitions through training has implications for prevention.

Preventing postnatal depression: a causal mediation analysis of a 20-year preconception cohort.

Postnatal depression (PND) is common and predicts a range of adverse maternal and offspring outcomes. PND rates are highest among women with persistent mental health problems before pregnancy, and antenatal healthcare provides ideal opportunity to intervene. We examined antenatal perceived social support as a potential intervention target in preventing PND symptoms among women with prior mental health problems. A total of 398 Australian women (600 pregnancies) were assessed repeatedly for mental health problems before pregnancy (ages 14-29 years, 1992-2006), and again during pregnancy, two months postpartum and one year postpartum (2006-2014). Causal mediation analysis found that intervention on perceived antenatal social support has the potential to reduce rates of PND symptoms by up to 3% (from 15 to 12%) in women with persistent preconception symptoms. Supplementary analyses found that the role of low antenatal social support was independent of concurrent antenatal depressive symptoms. Combined, these two factors mediated up to more than half of the association between preconception mental health problems and PND symptoms. Trialling dual interventions on antenatal depressive symptoms and perceived social support represents one promising strategy to prevent PND in women with persistent preconception symptoms. Interventions promoting mental health before pregnancy may yield an even greater reduction in PND symptoms by disrupting a developmental cascade of risks via these and other pathways. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Patient decision aids for antidepressant use in pregnancy: a pilot randomised controlled trial in the UK.

BACKGROUND: Decision-making regarding antidepressant use in pregnancy is challenging, given the uncertain evidence base on the benefits and risks for women and their children. Patient decision aids (PDAs) can improve shared decision-making for complex health decisions but no evidence-based PDAs exist for antidepressant use in pregnancy. AIM: To assess the feasibility of a full-scale randomised controlled trial (RCT) to evaluate the efficacy of an electronic PDA on antidepressant use in pregnancy. DESIGN & SETTING: A UK-based pilot parallel-group RCT. METHOD: The study recruited women whose clinicians recommended an antidepressant for depression in a current or planned pregnancy, and who were uncertain about antidepressant use while pregnant. Women were recruited via clinician or self-referral, and randomised to online access to the PDA or online access to standard resource list, with primary follow-up at 4 weeks and longer-term follow-up. The primary outcome was protocol feasibility (recruitment target of 50 women and follow-up rate of 80%). Outcome measures for a future full-scale RCT included the decisional conflict scale (DCS). RESULTS: Fifty-one women were recruited with a follow-up rate of 90.2% at 4 weeks. The PDA received good overall satisfaction ratings (mean 4.2/5). Analysis of covariance (ANCOVA) indicated a small improvement in decisional conflict at 4 weeks, accounting for baseline scores (DCS regression coefficient = -3.5, 95% confidence intervals [CI = -12.6 to 5.6]). CONCLUSION: This pilot RCT for an electronic PDA on antidepressant use in pregnancy showed that the study protocol was feasible, with high rates of participant satisfaction among those randomised to the PDA.

The association between a history of self-harm and mental disorders in pregnancy.

BACKGROUND: Self-harm is prevalent, particularly among young women, and is associated with mental disorders. However, little is known about the mental health of pregnant women who have a history of self-harm. This study examined whether lifetime self-harm was associated with increased risk of antenatal mental disorders. METHODS: Cross-sectional study of 544 pregnant women recruited after their first antenatal appointment, oversampling those who responded positively to the depression-screening Whooley questions. The Structured Clinical Interview for DSM-IV-TR was delivered, including questions about the lifetime occurrence of self-harm. The associations between lifetime self-harm and the presence of mental disorders, and more specifically anxiety and depressive disorders, were examined using survey-weighted logistic regression. The association between lifetime self-harm and symptoms of personality disorder, was investigated using survey-weighted linear regression. RESULTS: After survey weighting, history of self-harm had a prevalence of 7.9% (95%CI 5.5-11.2%) and was associated with increased risk for mental disorders in early pregnancy (adjusted odds ratio [AOR] 5.03; 95%CI: 2.22-11.37; p < 0.0001; n = 517). Women with a history of self-harm were more likely to experience antenatal anxiety disorders (AOR 4.41; 95%CI: 1.85-10.51; p = 0.001; n = 517) and antenatal depression (AOR 2.71; 95%CI: 1.04-7.05; p = 0.042; n = 517) than women who did not report self-harm. History of self-harm was also associated with higher SAPAS scores (adjusted coefficient 0.69; 95%CI: 0.21-1.17; n = 517). LIMITATIONS: Information on the timing and persistence of self-harm was not available. CONCLUSIONS: Women with a history of self-harm are more vulnerable to mental disorders in pregnancy. Further research should include more comprehensive assessments of self-harm and the social context of pregnant women.

Crisis-planning interventions for people with psychotic illness or bipolar disorder: systematic review and meta-analyses.

BACKGROUND: Mental health services lack a strong evidence base on the most effective interventions to reduce compulsory admissions. However, some research suggests a positive impact of crisis-planning interventions in which patients are involved in planning for their future care during a mental health crisis. AIMS: This review aimed to synthesise randomised controlled trial (RCT) evidence on the effectiveness of crisis-planning interventions (for example advance statements and joint crisis plans) in reducing rates of compulsory hospital admissions for people with psychotic illness or bipolar disorder, compared with usual care (PROSPERO registration number: CRD42018084808). METHOD: Six online databases were searched in October 2018. The primary outcome was compulsory psychiatric admissions and secondary outcomes included other psychiatric admissions, therapeutic alliance, perceived coercion and cost-effectiveness. Bias was assessed using the Cochrane collaboration tool. RESULTS: The search identified 1428 studies and 5 RCTs were eligible. One study had high risk of bias because of incomplete primary outcome data. Random-effects meta-analysis showed a 25% reduction in compulsory admissions for those receiving crisis-planning interventions compared with usual care (risk ratio 0.75, 95% CI 0.61-0.93, P = 0.008; from five studies). There was no statistical evidence that the intervention reduced the risk of voluntary or combined voluntary and compulsory psychiatric admissions. Few studies assessed other secondary outcomes. CONCLUSIONS: Our meta-analysis suggests that crisis-planning interventions substantially reduce the risk of compulsory admissions among individuals with psychotic illness or bipolar disorder. Despite common components, interventions varied in their content and intensity across the trials. The optimal models and implementation of these interventions require further investigation. DECLARATION OF INTEREST: E.M., S.L., S.J. and B.L.-E. received funding from the National Institute for Health Research during the conduct of the study.