The validity of the EPDS tool in detecting PPD was recently examined in a systematic review of 37 studies. Gibson et al42 concluded that the heterogeneity of these studies (ie, differences in study methodology, language used, and diagnostic criteria) precluded meta-analysis and did not provide clear support of EPDS as an accurate screening tool for PPD, especially across diverse cultures. In a similar review, Hewitt and colleagues6 sought to “provide an overview of all available methods to identify postnatal depression in primary care and to assess their validity.” They concluded that the EPDS is the most frequently reported screening tool and, with an overall sensitivity of 86% and overall specificity of 87%, its diagnostic performance seems “reasonably good.”6 Of note, fewer data have been collected to demonstrate the effectiveness of other screening tools.35,36,38,41
Cost-effectiveness is a consideration in the use of screening programs for PPD. According to a hypothetical cohort analysis conducted in the UK, the costs of treating women with false-positive screening results made implementation of a formal screening strategy for PPD not cost-effective, compared with usual care only, for use by the British National Health Service.43
MANAGEMENT
Once PPD is identified, treatment should be initiated as quickly as possible; referral for psychological counseling is an appropriate initial strategy for mild to moderate symptoms of PPD.5 A clinical care manager can be a valuable resource to provide education and coordination of care for women affected by PPD. NPs and PAs in primary care, obstetrics/gynecology, women’s health, and psychiatry or psychology can play an important role in the identification and management of PPD.
Treatment of PPD involves combination therapy—short-term psychological therapy combined with pharmacotherapy. According to investigators in a Cochrane Review of nine trials reporting short-term outcomes for 956 women with PPD, their findings suggest that psychosocial and psychological interventions are an effective option for reducing symptoms of PPD.44 Compared with usual care, the types of psychological therapy that were found most effective included cognitive behavioral therapy, interpersonal therapy, and psychodynamic therapy. As most trials’ follow-up periods were limited to six months, however, neither the long-term effects of psychological therapy nor the relative effectiveness of each type of therapy was made clear by these studies.44,45
Pharmacotherapy
Although antidepressant drugs are known to be effective for the treatment of major depressive disorder, well-designed clinical trials demonstrating the overall effectiveness of antidepressants in treatment of PPD have been limited.46 According to Ng et al,46 who in 2010 performed a systematic review of studies examining pharmacologic interventions for PPD, preliminary evidence showing the effectiveness of antidepressants and hormone therapy should prompt the initiation of larger, more rigorous randomized and controlled trials.
The choice of antidepressants will be influenced by the mother’s breastfeeding status and whether PPD represents her first episode of depression or a recurrence of previous major depression. If the patient is not breastfeeding, the choice among antidepressants is similar to those used for treatment of nonpuerperal major depression. If PPD is a relapse of a prior depression, the therapeutic agent that was most effective and best-tolerated for previous depression should be prescribed.47
Generally, the SSRIs are considered first-line agents because of their superior safety profile.47 Fluoxetine has been shown in a small randomized trial (n = 87) to be significantly more effective than placebo and as effective as a full course of cognitive-behavioral counseling.45 In non–placebo-controlled studies, sertraline, fluvoxamine, and venlafaxine all produced improvement in PPD symptoms.48,49
Whether the mother is breastfeeding her infant will influence the use and choice of antidepressants for PPD. Although barely detectable levels of certain antidepressant medications (including the SSRIs sertraline and paroxetine, and the tricyclic antidepressant nortriptyline) have been reported in breast milk or in infant serum,50,51 it is recommended that the lowest possible therapeutic dose be prescribed, and that infants be carefully monitored for adverse effects.51
Fluoxetine, it should be noted, has been found to be transmitted through breast milk and was associated with reduced infant weight gain (specifically, by 392 g over six months) in a comparison between 64 fluoxetine-treated mothers and 38 non-treated mother-infant pairs.52 Thus, fluoxetine use should be avoided in women who are breastfeeding.
In small studies, paroxetine and fluvoxamine were not detected in infant serum, and although low levels of sertraline were detected in one-fourth of infants whose mothers received doses exceeding 100 mg/d, no adverse infant outcomes were noted.52-54 Paroxetine, nortriptyline, and sertraline appear to be relatively safer antidepressant choices in breastfeeding women with PPD.50,52,53
Antidepressants should be continued for six months after full remission of depressive symptoms. Longer courses of therapy may be necessary in patients who experience recurrent major depressive episodes.55