Evidence
This page contains a snapshot of featured content which highlights evidence addressing key clinical questions including areas of uncertainty. Please see the main topic reference list for details of all sources underpinning this topic.
BMJ Best Practice evidence tables
Evidence tables provide easily navigated layers of evidence in the context of specific clinical questions, using GRADE and a BMJ Best Practice Effectiveness rating. Follow the links at the bottom of the table, which go to the related evidence score in the main topic text, providing additional context for the clinical question. Find out more about our evidence tables.
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is very low or low where GRADE has been performed and there may be no difference in effectiveness between the intervention and comparison for key outcomes. However, this is uncertain and new evidence could change this in the future.
Population: Women who are pregnant or in the postnatal period with no pre-defined risk factors for developing postnatal depression
Intervention: Psychosocial interventions
Comparison: Treatment as usual (TAU) or enhanced TAU
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
Listening visits versus TAU | ||
Depression symptomatology post-treatment: Intention-to-treat (ITT) analysis (follow-up mean 26 weeks; assessed with Edinburgh postnatal Depression Scale [EPDS] ≥12) | Favours intervention | Moderate |
Depression mean scores post-treatment: available case analysis (follow-up mean 26 weeks; measured with EPDS) | Favours intervention | Moderate |
Psychologically (CBT/IPT)-informed psychoeducation versus enhanced TAU | ||
Depression symptomatology post-treatment: ITT analysis (follow-up 4-17 weeks; assessed with EPDS ≥10 or Leverton Questionnaire ≥12) | No statistically significant difference | Low |
Depression symptomatology short follow-up (9-16 weeks post-intervention): ITT analysis (follow-up mean 12 weeks; assessed with EPDS ≥10) | No statistically significant difference | Low |
Depression symptomatology intermediate follow-up (17-24 weeks post-intervention): ITT analysis (follow-up mean 25 weeks; assessed with EPDS ≥10) | No statistically significant difference | Low |
Home visits versus TAU | ||
Depression mean scores post-treatment: available case analysis (follow-up mean 6 weeks; measured with EPDS) | No statistically significant difference | Moderate |
Depression mean scores intermediate follow-up (17-24 weeks post-intervention): available case analysis (follow-up mean 26 weeks; measured with EPDS) | No statistically significant difference | Moderate |
Post-delivery discussion versus TAU | ||
Depression symptomatology post-treatment: available case analysis (follow-up mean 3 weeks; assessed with Hospital Anxiety and Depression Scale – Depression [HADS] ≥11) | Favours intervention | Low |
Mother–infant relationship interventions versus enhanced TAU | ||
Depression mean scores post-treatment: ITT analysis (follow-up mean 26 weeks; measured with Beck Depression Inventory [BDI]) | No statistically significant difference | Low |
Mindfulness training versus TAU | ||
Depression mean scores post-treatment: available case analysis (follow-up mean 11 weeks; measured with Depression, Anxiety, and Stress Scale [DASS-21]: Depression) | No statistically significant difference | Low |
Recommendations as stated in the source guideline The UK National Institute of Health and Care Excellence (NICE) guideline did not make any recommendation for psychosocial interventions as part of routine antenatal or postnatal care. This was based on the clinical evidence above and the health economic evidence (see Notes below).
Note The health economic evidence included four studies evaluating preventative psychosocial interventions (e.g., home visits and listening visits). In general they found better outcomes but with increased costs, and as no studies reported Quality Adjusted Life Years (QALYs), it was not possible to reach any conclusions regarding cost effectiveness. Where ITT analysis is available, it has been reported in preference to available case analysis.
This evidence table is related to the following section/s:
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is very low or low where GRADE has been performed and the intervention may be more effective/beneficial than the comparison for key outcomes. However, this is uncertain and new evidence could change this in the future.
Population: Women who develop depression during pregnancy or the postnatal period
Intervention: Cognitive behavioural therapy (CBT) or interpersonal psychotherapy (IPT)
Comparison: Treatment as usual (TAU) or enhanced TAU
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
Depression diagnosis post-treatment: intention-to-treat (ITT) analysis (follow-up 12-44 weeks; assessed with Structured Clinical Interview [SCID] or Clinical Interview Schedule – Revised [CIS-R]) | Favours intervention | High |
Depression symptomatology post-treatment: ITT analysis (follow-up 6-44 weeks; assessed with Edinburgh Postnatal Depression Scale (EPDS) ≥10/EPDS ≥12/treatment non-response [baseline-endpoint decrease <4 points and EPDS >13]/treatment non-response [<50% improvement] or Beck Depression Inventory [BDI] ≥16 or BDI-II ≥14) | Favours intervention | Low |
Depression mean scores post-treatment: ITT analysis (follow-up 6-44 weeks; measured with EPDS or BDI-II) | Favours intervention | Very Low |
Depression diagnosis short follow-up (9-16 weeks post-intervention): ITT analysis (follow-up mean 28 weeks; assessed with SCID) | Favours intervention | Low |
Depression symptomatology short follow-up (9-16 weeks post-intervention) ITT analysis (follow-up mean 29 weeks; assessed with BDI-II ≥14) | No statistically significant difference | Low |
Depression mean scores short follow-up (9-16 weeks post-intervention): ITT analysis (follow-up 28-29 weeks; measured with EPDS or BDI-II) | No statistically significant difference | Very Low |
Depression diagnosis Intermediate follow-up (17-24 weeks post-intervention): ITT analysis (follow-up mean 33 weeks; assessed with CIS-R or SCID) | No statistically significant difference | Very Low |
Depression mean depression scores intermediate follow-up (17-24 weeks post-intervention): available case analysis (follow-up mean 33 weeks; measured with EPDS) | No statistically significant difference | Very Low |
Depression diagnosis long follow-up (25-103 weeks post-intervention): ITT analysis (follow-up mean 78 weeks; assessed with SCID) | No statistically significant difference | Low |
Depression symptomatology long follow-up (25-103 weeks post-intervention): ITT analysis (follow-up mean 32 weeks; assessed with EPDS ≥10) | No statistically significant difference | Very Low |
Depression mean scores long follow-up (25-103 weeks post-intervention): available case analysis (follow-up 32-78 weeks; measured with EPDS or BDI) | No statistically significant difference | Low |
Depression diagnosis very long follow-up (>104 weeks post-intervention): ITT analysis (follow-up mean 260 weeks; assessed with SCID) | Favours comparison | Low |
Depression mean depression scores very long follow-up (>104 weeks post-intervention): available case analysis (follow-up mean 260 weeks; measured with EPDS) | No statistically significant difference | Low |
Negative thoughts/mood mean scores: available case analysis (follow-up mean 4 weeks; measured with Automatic Thought Questionnaire [ATQ]) | Favours intervention | Very Low |
Recommendations as stated in the source guideline For a woman with moderate or severe depression in pregnancy or the postnatal period, consider the following options: a high-intensity psychological intervention (for example, CBT), a tricyclic antidepressant (TCA), selective serotonin-reuptake inhibitor (SSRI), or serotonin-noradrenaline reuptake inhibitor (SNRI) if the woman understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and: she has expressed a preference for medication, or she declines psychological interventions, or her symptoms have not responded to psychological interventions, a high-intensity psychological intervention in combination with medication if the woman understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period, and there is no response, or a limited response, to a high-intensity psychological intervention or medication alone.
Note The guideline group noted that in the short term (9-16 weeks post intervention) CBT or IPT were more effective than TAU or enhanced TAU. However, at 17 to 24 weeks there was more uncertainty due to very wide 95% confidence intervals which crossed the line of no effect for many outcomes. In the longer term (>24 weeks post intervention), the evidence was noted to be very inconsistent. Where ITT analysis is available, it has been reported in preference to available case analysis.
This evidence table is related to the following section/s:
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