背景:孕妇在怀孕期间的抑郁症很普遍,并且与早产(PTD)的风险增加有关。然而,两种常用治疗方案的有效性比较,心理健康咨询和抗抑郁药的使用,在降低与母亲抑郁相关的PTD风险方面仍不确定.尽管在许多先前的研究中,抗抑郁药的使用与PTD的风险增加有关,尚未研究这两种治疗方案之间的直接头对头比较.因此,这两种治疗方案的相对风险-获益情况尚不清楚.
目的:确定两种常用的治疗产前抑郁症的方法在限制与母亲抑郁症相关的PTD风险方面的相对有效性。
方法:在北加州KaiserPermanente(KPNC)的82,170名孕妇中进行了一项大型前瞻性队列研究,综合保健系统。从KPNC电子健康记录系统(EHR)中确定了临床诊断的抑郁症及其治疗方法(使用抗抑郁药和心理健康咨询)。还记录了所有分娩的妊娠年龄,并由EHR捕获以确定PTD。
结果:使用Cox比例风险回归结合倾向评分方法,以确保比较队列之间的可比性,相对于那些没有抑郁症的人,未经治疗的抑郁症孕妇的PTD风险增加41%:校正风险比(aHR)=1.41,95%置信区间(CI)=1.24~1.60,证实PTD相关的潜在母体抑郁症风险增加.相对于未经治疗的抑郁症,任何心理健康咨询与PTD风险降低18%相关:aHR=0.82(0.71-0.96).反向关联显示剂量-反应模式:咨询访问次数的增加与PTD风险的降低有关,与4次或更多次访问相关的PTD风险降低43%(aHR=0.57,95%CI=0.45-0.73)。相比之下,妊娠期使用抗抑郁药与PTD风险额外增加31%相关,而与基础抑郁无关:aHR=1.31,95%CI=1.06~1.61.这种正相关也显示了剂量-反应关系:更长的使用时间与更高的风险相关。
结论:这项研究为PTD风险背景下两种常见的产前抑郁症治疗方案的相对有效性提供了急需的证据。结果表明,降低因产妇抑郁而导致的PTD风险,心理健康咨询更有效。使用抗抑郁药可能会增加PTD的额外风险,独立于潜在的抑郁症。这些发现为临床医生和孕妇提供了数据,以做出基于证据的知情治疗决定,考虑到对孕产妇和胎儿健康的风险和益处。
BACKGROUND: Maternal depression during pregnancy is prevalent and has been associated with increased risk of preterm delivery (PTD). However, comparative effectiveness of two commonly used treatment options, mental health counseling and use of antidepressants, in mitigating the risk of PTD associated with maternal depression remains uncertain. Although antidepressant use has been associated with increased risk of PTD in many previous studies, a direct head-to-head comparison between these two treatment options has not been investigated. Thus, the comparative risk-benefit profiles of those two treatment options remain unclear.
OBJECTIVE: To determine the comparative effectiveness of two commonly used options for treating prenatal depression in limiting the risk of PTD associated with maternal depression.
METHODS: A large prospective cohort study was conducted among 82,170 pregnant women at Kaiser Permanente Northern California (KPNC), an integrated health delivery system. Clinically diagnosed depression and its treatments (use of antidepressants and mental health counseling) were identified from the KPNC electronic health record system (EHR). Gestational age was also recorded for all deliveries and captured by EHRs for determining PTD.
RESULTS: Using Cox proportional hazards regression incorporating propensity score methodology to ensure comparability between comparison cohorts, relative to those without depression, pregnant women with untreated depression had 41% increased risk of PTD: adjusted hazard ratio (aHR)=1.41, 95% confidence interval (CI)=1.24-1.60, confirming increased risk of PTD associated underlying maternal depression. Relative to untreated depression, any mental health counseling was associated with a 18% of reduced risk of PTD: aHR=0.82 (0.71-0.96). The inverse association showed a dose-response pattern: increased number of counseling visits was associated with greater reduction in PTD risk with 43% reduction in PTD risk associated with 4 or more visits (aHR=0.57, 95% CI=0.45-0.73). In contrast, use of antidepressants during pregnancy was associated with an additional 31% increased risk of PTD independent of underlying depression: aHR=1.31, 95% CI=1.06-1.61. This positive association also showed a dose-response relationship: a longer duration of use was associated with an even higher risk.
CONCLUSIONS: This study provides much needed evidence regarding the comparative effectiveness of two common treatment options for prenatal depression in the context of PTD risk. The results indicate that, to reduce PTD risk due to maternal depression, mental health counseling is more effective. Use of antidepressants may add additional risk of PTD, independent of the underlying depression. The findings provide data for clinicians and pregnant women to make informed and evidence-based treatment decisions that take into account the risks and benefits to both maternal and fetal health.