Evidence-Based Reviews

Postpartum depression: Help patients find the right treatment

Current Psychiatry. 2012 November;11(11):14-21

Accessibility of treatment, patient preference, breast-feeding help guide decisions

References

1. Cicchetti D, Rogosch FA, Toth SL. Maternal depressive disorder and contextual risk: contributions to the development of attachment insecurity and behavior problems in toddlerhood. Dev Psychopathol. 1998;10(2):283-300.

2. Murray L, Fiori-Cowley A, Hooper R, et al. The impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcome. Child Dev. 1996;67(5):2512-2526.

3. Sharp D, Hay DF, Pawlby S, et al. The impact of postnatal depression on boys’ intellectual development. J Child Psychol Psychiatry. 1995;36(8):1315-1336.

4. Altshuler LL, Hendrick V, Cohen LS. Course of mood and anxiety disorders during pregnancy and the postpartum period. J Clin Psychiatry. 1998;59(suppl 2):29-33.

5. Pariser SF. Women and mood disorders. Menarche to menopause. Ann Clin Psychiatry. 1993;5(4):249-254.

6. Dennis CL, Janssen PA, Singer J. Identifying women at-risk for postpartum depression in the immediate postpartum period. Acta Psychiatr Scand. 2004;110(5):338-346.

7. Chaudron LH, Klein MH, Remington P, et al. Predictors, prodromes and incidence of postpartum depression. J Psychosom Obstet Gynaecol. 2001;22(2):103-112.

8. Heron J, O’Connor TG, Evans J, et al. ALSPAC Study Team. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J Affect Disord. 2004;80(1):65-73.

9. Wenzel A, Haugen EN, Jackson LC, et al. Anxiety symptoms and disorders at eight weeks postpartum. J Anxiety Disord. 2005;19(3):295-311.

10. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-786.

11. Evins GG, Theofrastous JP, Galvin SL. Postpartum depression: a comparison of screening and routine clinical evaluation. Am J Obstet Gynecol. 2000;182(5):1080-1082.

12. Flynn HA, O’Mahen HA, Massey L, et al. The impact of a brief obstetrics clinic-based intervention on treatment use for perinatal depression. J Womens Health (Larchmt). 2006;15(10):1195-1204.

13. Yonkers KA, Smith MV, Lin H, et al. Depression screening of perinatal women: an evaluation of the healthy start depression initiative. Psychiatr Serv. 2009;60(3):322-328.

14. van Schaik DJ, Klijn AF, van Hout HP, et al. Patients’ p in the treatment of depressive disorder in primary care. Gen Hosp Psychiatry. 2004;26(3):184-189.

15. Boath E, Bradley E, Henshaw C. Women’s views of antidepressants in the treatment of postnatal depression. J Psychosom Obstet Gynaecol. 2004;25(3-4):221-233.

16. Pearlstein TB, Zlotnick C, Battle CL, et al. Patient choice of treatment for postpartum depression: a pilot study. Arch Womens Ment Health. 2006;9(6):303-308.

17. Zlotnick C, Johnson SL, Miller IW, et al. Postpartum depression in women receiving public assistance: pilot study of an interpersonal-therapy-oriented group intervention. Am J Psychiatry. 2001;158(4):638-640.

18. Klier CM, Muzik M, Rosenblum KL, et al. Interpersonal psychotherapy adapted for the group setting in the treatment of postpartum depression. J Psychother Pract Res. 2001;10(2):124-131.

19. Stuart S, O’Hara MW, Gorman LL. The prevention and psychotherapeutic treatment of postpartum depression. Arch Womens Ment Health. 2003;6(suppl 2):S57-S69.

20. Appleby L, Warner R, Whitton A, et al. A controlled study of fluoxetine and cognitive-behavioural counselling in the treatment of postnatal depression. BMJ. 1997;314(7085):932-936.

21. Yonkers KA, Lin H, Howell HB, et al. Pharmacologic treatment of postpartum women with new-onset major depressive disorder: a randomized controlled trial with paroxetine. J Clin Psychiatry. 2008;69(4):659-665.

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Postpartum depression (PPD)—emergence of a major depressive episode after childbirth—has broad negative consequences for the mother, baby, and other family members. The time of onset after delivery for a depressive episode to be considered postpartum is debatable, but the DSM-IV-TR specifier states that onset within 4 weeks of childbirth is considered postpartum. PPD can impact many aspects of child development, including mother-infant attachment, cognitive development, and behavior.^1-3

An estimated 10% of women who have given birth experience PPD.^4,5 The risk of PPD is particularly high among women who have had previous episodes of PPD or major depressive disorder (MDD). Other risk factors include stressful life events, depression and/or anxiety during pregnancy, family history of PPD, and obstetrical complications.^6-8 Anxiety disorders are common in postpartum women, and anxiety symptoms often are prominent in PPD.⁹

Despite the prevalence of PPD and its serious consequences, few studies have addressed antidepressant treatment. In this article we discuss screening and treating PPD and considerations for breast-feeding mothers. Click here for results of an open-label trial of escitalopram for PPD we conducted in which patient recruitment was challenging.

Screening for PPD: A good start

Initiatives by state governments and health care providers have led to programs in which universal screening for PPD has been implemented. Screening provides a mechanism for early detection and intervention. The Edinburgh Postnatal Depression Scale¹⁰ is a self-rated, 10-item scale developed for the postpartum setting, and its use increases identification of PPD at postpartum obstetrics visits.¹¹ Other screening tools such as the Patient Health Questionnaire-9 also are commonly used. Despite the success of screening programs in attempting the feasibility of screening, it is unclear if the identification of women who may be experiencing PPD increases their engagement in treatment. Studies have demonstrated that even when depressive symptoms suggesting a PPD episode are identified in the postpartum period, many women still do not receive treatment.^12,13 Studies of PPD screening programs have not demonstrated that screening itself improves treatment engagement or improves outcomes.^12,13

Clinical Point

Use of the self-rated, 10-item Edinburgh Postnatal Depression Scale increases identification of PPD at obstetrics visits

Multiple factors—including accessibility of treatment options and patient preference for specific types of treatment—determine whether mothers with PPD obtain treatment. Patients diagnosed with depression by a primary care clinician may prefer psychotherapy to antidepressants,¹⁴ and a postpartum mother’s willingness to accept antidepressant treatment may be influenced by concerns about possible risks during breast-feeding.¹⁵

Psychotherapy: An effective option

Psychotherapy is an important first-line option for PPD, particularly because of considerations of medication exposure during breast-feeding and many women are reluctant to take antidepressants while breast-feeding.¹⁶ Interpersonal psychotherapy and cognitive-behavioral therapy (CBT) have been most studied for PPD, and both appear effective for prevention and acute treatment of PPD.^17-20 Although psychotherapy alone may be sufficient for some women, for others, medication may be an important first-line treatment, depending on symptom severity, access to psychotherapy, and personal preference.

Evidence for antidepressants

Clinical Point

In a randomized, double-blind study, CBT plus fluoxetine was significantly more effective than CBT plus placebo

Table 1^20-27 describes clinical trials that assessed the efficacy of antidepressants for PPD. Two relatively small, double-blind, placebo-controlled trials have evaluated selective serotonin reuptake inhibitors for PPD. In a randomized, double-blind study of CBT plus fluoxetine or CBT plus placebo (N = 87), fluoxetine was significantly more effective than placebo.²⁰ In a randomized, controlled trial of paroxetine vs placebo for PPD (N = 70), both groups improved as measured by the 17-item Hamilton Rating Scale for Depression or Inventory of Depressive Symptomatology-Self-Report; those who received paroxetine did not improve significantly more than those who received placebo.²¹ It is difficult to interpret a negative, underpowered study because placebo response rates in antidepressant trials of MDD tend to be high. Data from placebo-controlled trials in PPD are limited by the number and power of those trials.

Randomization to placebo is rare in PPD trials. Most trials have used open-label designs because placebo arms pose ethical dilemmas considering the impact of PPD on a mother and her baby. In a randomized study of sertraline or nortriptyline for PPD, both drugs were similarly efficacious.²² In another study comparing paroxetine monotherapy and paroxetine plus CBT for PPD, both groups experienced significant improvement in depression and anxiety symptoms, with no difference between groups at endpoint.²³ Open-label trials have suggested antidepressants’ efficacy, although some studies have included small sample sizes (Table 1).^20-27

Table 1

Antidepressants for PPD: Summary of the evidence