妊娠及产后抑郁症的抗抑郁药物治疗。

Marian McDonagh, Annette Matthews, Carrie Phillipi, Jillian Romm, Kim Peterson, Sujata Thakurta, Jeanne-Marie Guise
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引用次数: 12

摘要

目的:评价妊娠期及产后抑郁症药物治疗的利与弊。数据来源:Cochrane系统评价数据库、Cochrane中央对照试验注册库、护理与相关健康文献累积索引(CINAHL)、MEDLINE、Scopus、ClinicalTrials.gov和制药商科学信息包。数据库从成立到2013年7月进行了搜索。回顾方法:我们纳入了比较怀孕期间或怀孕后抑郁症的药物治疗、非药物治疗、常规护理或不治疗的研究。结果包括母亲和婴儿或儿童的益处和危害。研究纳入、数据提取和质量评价采用双重评价。我们使用药物有效性评价项目的方法评估研究质量。我们根据有效医疗保健计划的方法对证据体的强度进行了分级。直接证据包括比较感兴趣人群(即抑郁症妇女)中感兴趣的干预措施并测量感兴趣结果的研究。将抑郁女性与没有抑郁迹象的对照组进行比较的研究被认为是间接的。结果:我们纳入了15项观察性研究,这些研究提供了直接证据,证明抗抑郁药对怀孕期间抑郁症的益处和危害。我们纳入了六项随机对照试验和两项观察性研究,研究了产后妇女抑郁症的抗抑郁治疗。对抑郁孕妇的研究主要比较了抗抑郁治疗和不治疗,对产后妇女的研究也比较了单独抗抑郁治疗和联合抗抑郁-非药物治疗。该证据不足以得出抗抑郁药对孕妇或产后抑郁症妇女的母亲抑郁症状、功能能力、母乳喂养、母婴相互作用以及婴儿和儿童发育结果的比较利弊的结论。低强度证据表明,怀孕期间服用选择性血清素再摄取抑制剂(SSRIs)的抑郁症妇女的新生儿比未服用的妇女的新生儿有更高的呼吸窘迫风险,但早产或新生儿惊厥的风险在这两组之间没有差异。在子宫内接触抗抑郁药导致重大畸形和新生儿发育风险的直接证据不足以得出结论。对于患有抑郁症的产后妇女,证据不足以评估治疗的全部益处和危害。低强度的证据无法显示在SSRIs中加入简短的心理治疗或认知行为治疗的益处。为了解决直接证据的空白,我们纳入了另外109项观察性研究,将因混合或未报告的原因接受抗抑郁药物治疗的孕妇与未服用抗抑郁药物且抑郁状态未知的孕妇进行比较。这一间接证据表明,未来的研究应侧重于先天性异常和新生儿运动发育迟缓的比较风险。虽然在怀孕期间使用抗抑郁药与儿童患自闭症谱系障碍或注意缺陷多动障碍的绝对风险增加可能非常小,但这一问题也值得在未来的研究中得到重视。未来的研究应该比较现有的治疗方法,并有足够的样本量。调查还应考虑潜在的混杂因素,包括年龄、种族、胎次、其他暴露(如酒精、吸烟和其他潜在的致畸物),以及剂量、抑郁严重程度、诊断时间或既往抑郁发作的影响。结论:关于孕妇和产后抑郁症药物治疗的比较利弊的证据在很大程度上是不充分的,无法做出明智的治疗决定。对于孕妇来说,这主要是因为对照组并不完全是抑郁的女性。对于产后妇女,缺乏证据主要是因为缺乏研究。这些都是主要的限制,因为抑郁症与严重的不良后果有关。鉴于抑郁症的普遍性及其对孕妇、新妈妈和儿童生活的影响,新的研究填补这一信息空白是必不可少的。
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Antidepressant Treatment of Depression During Pregnancy and the Postpartum Period.

Objectives: To evaluate the benefits and harms of pharmacological therapy for depression in women during pregnancy or the postpartum period.

Data sources: Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, Scopus, ClinicalTrials.gov, and Scientific Information Packets from pharmaceutical manufacturers. Databases were searched from their inception to July 2013..

Review methods: We included studies comparing pharmacological treatments for depression during or after pregnancy with each other, with nonpharmacological treatments, or with usual care or no treatment. Outcomes included both maternal and infant or child benefits and harms. Dual review was used for study inclusion, data abstraction, and quality assessment. We assessed study quality using methods of the Drug Effectiveness Review Project. We graded the strength of the body of evidence according to the methods of the Effective Health Care Program. Direct evidence comprised studies that compared interventions of interest in the population of interest (i.e., depressed women) and measured the outcomes of interest. Studies comparing groups of depressed women with control groups with no evidence of depression were considered indirect.

Results: We included 15 observational studies that provided direct evidence on benefits and harms of antidepressants for depression during pregnancy. We included six randomized controlled trials and two observational studies of antidepressant treatment for depression in postpartum women. Studies of depressed pregnant women primarily compared antidepressant treatment with no treatment, and studies of postpartum women also compared antidepressants alone with combination antidepressant-nonpharmacological treatments. This evidence was insufficient to draw conclusions on the comparative benefits or harms of antidepressants for the outcomes of maternal depression symptoms, functional capacity, breastfeeding, mother-infant dyad interactions, and infant and child development for either pregnant or postpartum women with depression. Low-strength evidence suggests that neonates of women with depression taking selective serotonin reuptake inhibitors (SSRIs) during pregnancy had higher risk of respiratory distress than neonates of untreated women but that risk of preterm birth or neonatal convulsions does not differ between these groups. Direct evidence on the risk of major malformations and neonatal development with exposure to antidepressants in utero was insufficient to draw conclusions. For postpartum women with depression, evidence was insufficient to evaluate the full range of benefits and harms of treatment. Low-strength evidence was unable to show a benefit of adding brief psychotherapy or cognitive behavioral therapy to SSRIs.

To address gaps in the direct evidence, we included an additional 109 observational studies of pregnant women receiving antidepressants for mixed or unreported reasons compared with pregnant women not taking antidepressants whose depression status was unknown. Signals from this indirect evidence suggest that future research should focus on the comparative risk of congenital anomalies and neonatal motor developmental delays. Although the absolute increased risk of autism spectrum disorder or attention-deficit hyperactivity disorder in the child associated with antidepressant use for depression in pregnancy may be very small, this issue also merits attention in future research. Future research should compare available treatments in groups of women with depression and have adequate sample sizes. Investigations should also take into account potential confounding, including age, race, parity, other exposures (e.g., alcohol, smoking, and other potential teratogens), and the impact of dose, severity of depression, timing of diagnosis, or prior depressive episodes.

Conclusions: Evidence about the comparative benefits and harms of pharmacological treatment of depression in pregnant and postpartum women was largely inadequate to allow well-informed decisions about treatment. For pregnant women, this was mainly because comparison groups were not exclusively depressed women. For postpartum women, the lack of evidence arose chiefly from a scarcity of studies. These are major limitations, as depression is known to be associated with serious adverse outcomes. Given the prevalence of depression and its impact on the lives of pregnant women, new mothers, and children, new research to fill this informational gap is essential.

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