Study designs of evaluations included in the review
There were no restrictions on the study designs eligible for inclusion in the review. The included studies were RCTs, quasi-controlled studies, cohort studies, open studies, descriptive reports, case studies and case series; one study was of an unknown design.
Specific interventions included in the review
Studies that clearly defined their main purpose as treatment were eligible. The included studies evaluated the following treatments:
pharmacological treatments, i.e. fluoxetine, sertraline, and S-adensylmethionine;
combined psychological and psychodynamic approaches, i.e. interactional/problem resolution, cognitive-behaviour therapy with and without counselling, group psychotherapy, listening visits, psychodynamic psychotherapy or interactional guidance, interpersonal psychotherapy, psychotherapy on mother-infant interaction, and counselling;
combined pharmacological and psychological approaches, i.e. fluoxetine plus cognitive-behavioural counselling and specialist day hospital;
social support and relaxation, i.e. social support group, group by mail, exercise and relaxation, massage, relaxation, and support group with and without partner;
hormonal, i.e. oestradiol skin patches and sublingual oestradiol;
other approaches, i.e.. bright light therapy; and
routine primary care (used as the control).
Participants included in the review
Studies of women with broadly defined postnatal depression were eligible regardless of the cause or time of onset of postnatal depression. Women with postpartum blues and puerperal psychosis were excluded.
Women were diagnosed with postnatal depression using the following criteria (where specified): American Psychiatric Association (APA) DSM-III-R and DSM-IV for major depression; Edinburgh Postnatal Depression Scale (EPDS) with and without further enquiry; Research Diagnostic Criteria (RDC) major or minor depression; Beck Depression Inventory (BDI); a score greater than 16 on BDI plus dysthymia on Diagnostic Inventory Schedule; a score greater than 35 on Current Experience Scale plus either greater than 21 on Multiple Affect Adjective Checklist or greater than 13 on EPDS; Hospital Anxiety and Depression Scale; and ICD-10 depression.
Some of the included studies also enrolled women with postnatal depression (criteria not specified), families with a child aged less than 30 months who had consulted a child guidance clinic, and women with postnatal depression plus borderline personality disorder.
Outcomes assessed in the review
The inclusion criteria were not defined in terms of the outcome. The included studies used at least 29 different instruments to assess the outcomes. The randomised controlled trials (RCTs) used the following criteria: Kellner Symptom Questionnaire (KSQ); SPI; EPDS; RDC diagnosis; BDI; Profile of Mood Status (POMS); Dyadic Adjustment Scale (DAS); Coopersmith Self-Esteem Inventory (CSEI); Social Provision Scale; Montgomery-Asberg Depression Rating Scale; APA DSM-III-R; depression section of the Structured Clinical Interview; Hamilton Depression Rating Scale (HAM-D/HDRS); Social Adjustment Scale; Inventory to Diagnose Depression; Postpartum Adjustment Questionnaire; Revised Clinical Interview Schedule; Behaviour Observation Scale; State Anxiety Instrument for Children; Mini International Neuropsychiatric Instrument; General Health Questionnaire; PBI; Parenting Stress Index (PSI); and Schedule for Affective Disorders and Schizophrenia (SADS-C). Urinary and salivary cortisol and pulse rate were also assessed.
How were decisions on the relevance of primary studies made?
The authors do not state how the papers were selected for the review, or how many of the reviewers performed the selection.