Assessing the evidence

We found 29 studies through surveillance of this guideline.

This included evidence to support current recommendations on case identification and assessment, experience of care, and pharmacological and non-pharmacological interventions.

We also identified evidence that was not consistent with current recommendations on access to services and exercise interventions. This evidence was considered to be insufficient in volume and conclusive results to change recommendations in these areas at this time. Topic expert opinion was sought as to whether this evidence would affect current recommendations. Generally, the topic experts agreed that the new evidence would not impact recommendations in these areas.

We did not find any evidence related to the organisation of perinatal mental health services. We also did not find any new evidence on postnatal post-traumatic stress disorder, which was an area considered to be important during post-publication correspondence.

Additionally, we identified relevant ongoing research due to be published in the next 3 to 5 years. There are 4 ongoing trials investigating the effectiveness of pharmacological treatments for postpartum depression which are due to publish by the end of 2017. Three studies investigating psychological or psychosocial treatments have completed recruitment at this time. One study has investigated strategies for postnatal depression screening and is currently in press. A further 3 studies are investigating the effectiveness of perinatal mental health service delivery. The progress of the ongoing studies will be monitored and they will be considered at the next surveillance review when results publish.

Equalities

No equalities issues were identified during the surveillance process.

Overall decision

After considering all the evidence and views of topic experts and stakeholders, we decided that an update is not necessary for this guideline.

See how we made the decision for further information.

What the guideline recommends

NICE guideline CG192 (recommendations 1.7.1, 1.7.2 and 1.7.5) recommends the use of psychosocial interventions to prevent and treat mental health problems in pregnant women. These interventions should be delivered by competent practitioners and be based on the relevant treatment manuals. Healthcare professionals should also understand how treatment could be affected by the variations in presentation and course of mental health problems. The guideline also recommends that these treatments should be provided within a stepped-care model of service delivery.

Methods

The Kenyon et al. (2016) randomised controlled trial investigated the effects of providing additional lay support to pregnant women with social risk factors. Participants were recruited from 3 maternity units in the UK. Nulliparous pregnant women under 28 weeks’ gestation were eligible for the study if social risk factors were identified during routine midwife antenatal appointments. Women who had previously given birth were excluded as were women aged under 16 years and teenagers who were already part of a separate trial. A prespecified subgroup of women with 2 or more social risk factors was also included in the analysis. The study considered the following as social risk factors:

• Housing problems
• Teen parent
• Smoking
• Difficulty with the English language
• UK resident for under 1 year
• Clinical diagnosis of past or present mental illness
• No support from either partner or family or friend
• BMI ≤18 or ≥35
• Booking after 18 weeks’ gestation
• In receipt of social services support
• Drug or alcohol misuse
• Domestic abuse
• Did not attend 2 or more antenatal appointments.

Computer-generated block randomisation was used to assign participants to either standard maternity care or addition of lay support. Assignment to treatment group was stratified according to the 3 maternity units. The additional lay support was provided by a pregnancy outreach worker (POW) service trained in individual case management and home visits. During pregnancy, the POW service provided social, emotional and practical support with an aim to encourage antenatal appointment attendance. During the initial 6-week postnatal period, the POW service provided advice about breastfeeding and infant care. Standard maternity care included referrals and signposting to specialist services other than the POW service.

The trial investigated the effects of additional lay support on 2 primary outcomes. Firstly, the attendance rate for all antenatal appointments, other than routine dating and abnormality scans, was calculated. Secondly, postnatal depression at 8 to 12 weeks after birth was measured using the Edinburgh Postnatal Depression Scale (EPDS). Secondary outcomes included maternal and neonatal birth outcomes. Maternal self-efficacy was measured using the Pearlin and Schooler Mastery Scale and bonding was measured with the Mother-to-infant Bonding Scale. Further secondary outcomes included attendance at child development assessments, breastfeeding and immunisation uptake.

Results

A total of 1,324 participants were randomised with 662 allocated to each intervention arm. Analyses included participants with available follow-up data. This consisted of 613 women in the standard care and 600 women in the POW groups.

Strengths and limitations

Impact on guideline

The results of this trial indicate some beneficial effects of additional lay support for pregnant women. However, the significant effect on depression symptoms is limited to the subgroup of women with 2 or more social risk factors. From this trial, it remains unclear how generalisable this result is to the wider antenatal population.

The inclusion of mother-to-infant bonding as an outcome is relevant to NICE guideline CG192 because the guideline contains recommendations and a research recommendation on this area. However, the relevance of the significant effect is limited because this is a secondary outcome in the trial and the guideline considers interventions specifically designed with a focus on the mother–baby relationship.

NICE guideline CG192 is unlikely to be impacted by the results of this study because of the above limitations in generalisability and applicability to recommendations. Also, because the guideline does not specify types of psychosocial interventions recommended for this population, lay support is unlikely to be added to the recommendations based on the results of this trial.

What the guideline recommends

NICE guideline CG192 (recommendations 1.8.1 and 1.8.3) recommends facilitated self-help for subthreshold to moderate depression and cognitive behaviour therapy (CBT) for moderate to severe depression in pregnancy and the postnatal period.

Although exercise is not specified as an intervention in the recommendations, it can form a component of both facilitated self-help and CBT during the behavioural elements of the interventions.

Methods

The Daley et al. (2015) systematic review and meta-analysis investigated the effects of exercise on antenatal depression. The search strategy identified randomised controlled trials (RCTs) of exercise as an intervention compared with any comparator. For inclusion in the review, exercise interventions were required to last for 6 weeks or more. Exercise when provided in conjunction with other interventions was also included within the review search. Trials with exercise as an intervention for either prevention or treatment of antenatal depression were included. For trials of treatment, pregnant women with a diagnosis or those identified at risk of depression were eligible for inclusion. For exercise as prevention, non-depressed pregnant women were also eligible for inclusion. Change in depression score from baseline to the final antenatal follow-up was the primary outcome. All included trials measured depression using the Centre for Epidemiological Studies depression scale (CES-D).

For the overall meta-analysis, all trial data were pooled with no distinction between populations or exercise intervention types. A prespecified subgroup analysis was performed comparing non-depressed with depressed or at risk populations. A further subgroup analysis was performed comparing aerobic with non-aerobic (yoga and tai chi) exercise interventions.

Results

The systematic review identified a total of 6 RCTs meeting the inclusion criteria. The trials included participants aged 14 to 38 years, recruited from 16 weeks’ gestation and with a total 348 pregnant women completing follow-up. One trial included a population of non-depressed women and evaluated an aerobic exercise intervention. The other 5 trials included women either at risk or depressed at baseline and evaluated non-aerobic exercise interventions. In all the included trials, exercise was used as a single intervention compared with standard prenatal care, wait-list control, parenting education sessions or social support as comparator groups. One trial included 3 treatment arms that was analysed as 2 separate comparisons within the meta-analysis. This gave a total of 7 comparisons for inclusion in the review.

The meta-analysis indicated a significant reduction in depression scores for exercise compared with controls (standardised mean difference [SMD] −0.46, 95% CI −0.87 to −0.05, p=0.03). However, the I² test for heterogeneity (68%) indicated that inconsistency across studies may be important.

No significant differences in depression scores were found in subgroup analyses comparing non-depressed with depressed women (p=0.32, I²=68%). Also, no significant differences in depression scores were found for the subgroup comparing aerobic with non-aerobic exercise interventions (p=0.32, I²=68%).

Strengths and limitations

Impact on guideline

The results of this study indicate some support for the use of exercise as a treatment for antenatal depression. However, the limitations of heterogeneity, small sample size and low quality of included trials result in uncertainty around the effects of exercise interventions for this population.

During the development of NICE guideline CG192, similar low-quality data were identified resulting in no specific recommendations for exercise interventions being made. Although this study will add to this evidence base, the limitations mean it is unlikely to impact on recommendations at this time. There remains uncertainty on the effectiveness of exercise interventions for the prevention and treatment of depression in an antenatal population.