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Depression Drug Treatment Outcomes in Pregnancy and the Postpartum Period: A Systematic Review and Meta-analysis

McDonagh, Marian, S., PharmD; Matthews, Annette, MD, MCR; Phillipi, Carrie, MD, PhD; Romm, Jillian, RN, LCSW; Peterson, Kim, MS; Thakurta, Sujata, MPA:HA; Guise, Jeanne-Marie, MD, MPH

doi: 10.1097/AOG.0000000000000410
Contents: Review

OBJECTIVE: To evaluate the comparative benefits and harms in both mother and child of antidepressant treatment for depression in pregnant or postpartum women.

DATA SOURCES: MEDLINE, the Cochrane Library, CINAHL, Scopus, (inception to July 2013), manufacturers, and reference lists.

METHODS OF STUDY SELECTION: Two reviewers independently selected studies of pregnant women with depression comparing antidepressants with each other, placebo or no treatment, or nondrug treatments. Studies making comparisons among women taking antidepressants for any reason and those not taking antidepressants (depression status unknown) were used to fill gaps in the evidence.

TABULATION, INTEGRATION, AND RESULTS: Dual study data extraction and quality assessment were used. Six randomized controlled trials and 15 observational studies provided evidence. Low-strength evidence suggested neonates of pregnant women with depression taking selective serotonin reuptake inhibitors had higher risk of respiratory distress than did neonates of untreated women (13.9% compared with 7.8%; P<.001) but no difference in risk of neonatal convulsions (0.14% compared with 0.11%; P=.64) or preterm birth (17% compared with 10%; P=.07). Indirect evidence from studies of pregnant women receiving antidepressants for mixed or unreported reasons compared with pregnant women not taking antidepressants (depression status unknown) suggested future research should focus on congenital anomalies and autism spectrum and attention deficit disorders in the child. In postpartum depression, low-strength evidence suggested symptom response was not improved when sertraline was added to psychotherapy or when cognitive–behavioral therapy was added to paroxetine. Evidence was insufficient for other outcomes, including depression symptoms, functional capacity, breastfeeding, and infant and child development. A serious limitation is the lack of study populations of exclusively depressed pregnant and postpartum women.

CONCLUSION: Evidence about the comparative benefits and harms of pharmacologic treatment of depression in pregnant and postpartum women was largely inadequate to allow informed decisions about treatment. Considering the prevalence of depression, filling this gap is essential.

Comparative evidence for maternal and child outcomes of treating depression in pregnancy and the postpartum period with antidepressants is largely inadequate to inform treatment-decision choices.

Departments of Medical Informatics and Clinical Epidemiology, Psychiatry, Pediatrics, and Obstetrics and Gynecology, Oregon Health and Science University, School of Medicine, and Portland Veterans Affairs Hospital, Portland, Oregon.

Corresponding author: Marian S. McDonagh, PharmD, Oregon Health & Science University, Mail Stop BICC, 3181 SW Sam Jackson Park Road, Portland, OR 97230; e-mail:

Funded by the Agency for Healthcare Research and Quality.

This project was funded under Contract No. HHSA 290200710057I from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by AHRQ or the U.S. Department of Health and Human Services.

The authors thank Leah Williams for editing and formatting, Tracy Dana, MLS, for literature search strategy development, and the technical expert panel who provided clinical and methodological insights on this work (no funding provided). Ms. Williams' and Ms. Dana's work was funded by our contract with the Agency for Healthcare Research and Quality.

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2014 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.