Evidence-Based Reviews

Postpartum depression: Help patients find the right treatment

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

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.

22. Wisner KL, Hanusa BH, Perel JM, et al. Postpartum depression: a randomized trial of sertraline versus nortriptyline. J Clin Psychopharmacol. 2006;(4)26:353-360.

23. Misri S, Reebye P, Corral M, et al. The use of paroxetine and cognitive-behavioral therapy in postpartum depression and anxiety: a randomized controlled trial. J Clin Psychiatry. 2004;65(9):1236-1241.

24. Stowe ZN, Casarella J, Landry J, et al. Sertraline in the treatment of women with postpartum major depression. Depression. 1995;3(1-2):49-55.

25. Cohen LS, Viguera AC, Bouffard SM, et al. Venlafaxine in the treatment of postpartum depression. J Clin Psychiatry. 2001;62(8):592-596.

26. Suri R, Burt VK, Altshuler LL, et al. Fluvoxamine for postpartum depression. Am J Psychiatry. 2001;158(10):1739-1740.

27. Nonacs RM, Soares CN, Viguera AC, et al. Bupropion SR for the treatment of postpartum depression: a pilot study. Int J Neuropsychopharmacol. 2005;8(3):445-449.

28. Burt VK, Suri R, Altshuler L, et al. The use of psychotropic medications during breast-feeding. Am J Psychiatry. 2001;158(7):1001-1009.

29. Weissman AM, Levy BT, Hartz AJ, et al. Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants. Am J Psychiatry. 2004;161(6):1066-1078.

30. Newport DJ, Ritchie JC, Knight BT, et al. Venlafaxine in human breast milk and nursing infant plasma: determination of exposure. J Clin Psychiatry. 2009;70(9):1304-1310.

31. Chaudron LH, Schoenecker CJ. Bupropion and breastfeeding: a case of a possible infant seizure. J Clin Psychiatry. 2004;65(6):881-882.

32. Hendrick V, Stowe ZN, Altshuler LL, et al. Fluoxetine and norfluoxetine concentrations in nursing infants and breast milk. Biol Psychiatry. 2001;50(10):775-782.

33. Sharma V, Khan M. Identification of bipolar disorder in women with postpartum depression. Bipolar Disord. 2010;12(3):335-340.

34. Austin MP, Hadzi-Pavlovic D, Priest SR, et al. Depressive and anxiety disorders in the postpartum period: how prevalent are they and can we improve their detection? Arch Womens Ment Health. 2010;13(5):395-401.

^28,29

The psychiatrist’s role

PPD has great public health significance because it affects a large number of women and their families. Screening during obstetrical visits or in other settings may increase identification of women who are suffering from PPD. In order for this screening to lead to meaningful changes, women must receive timely and expert evaluations for PPD and treatment that is efficacious and accessible.

Clinical Point

If a breast-feeding mother has had a good response to a specific antidepressant in the past, consider that medication

Psychiatrists often are called upon to treat women with postpartum illness, and whether the mother is breast-feeding or not may influence treatment decisions. When clinically warranted, antidepressants are an important option in the context of breast-feeding, although some antidepressants have more data available than others regarding use during lactation. If a mother has had a good response to a specific antidepressant in the past, that medication should be considered among the treatment options to avoid unnecessary medication trials and delayed response to treatment. Antidepressants with serotonergic action may be especially helpful if a woman presents with substantial postpartum anxiety. Psychotherapy is an important treatment for PPD; CBT and IPT are among the best-studied, efficacious treatments.

Diagnosis and treatment: 4 pearls

Verify the diagnosis. Many women who present with postpartum depressive symptoms may have previously unrecognized bipolar disorder, and many women presenting with a primary complaint of anxiety have PPD.^33,34

Discuss breast-feeding. This topic is important in assessing the risks and benefits of antidepressants in postpartum women, but many women also experience breast-feeding as a topic with emotional valence of its own and may need support with infant feeding.

Meet the patient where she is. Patient preferences strongly influence PPD treatment decisions. Women with similar clinical presentations may have strong preferences for different treatments.

Make treatment accessible. Postpartum women may find it challenging to engage in treatment. Treatment plans need to be feasible for women who are depressed while caring for a newborn. On-site childcare, home visits, Internet communication, and other accommodations that may facilitate treatment should be considered at a systems level.

Related Resources

American College of Obstetricians and Gynecologists. Screening for depression during and after pregnancy. www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Screening_for_Depression_During_and_After_Pregnancy.
Meltzer-Brody S. New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci. 2011;13(1):89-100.
Dennis CL, Stewart DE. Treatment of postpartum depression, part 1: a critical review of biological interventions. J Clin Psychiatry. 2004;65(9):1242-1251.
Dennis CL. Treatment of postpartum depression, part 2: a critical review of nonbiological interventions. J Clin Psychiatry. 2004;65(9):1252-1265.
Cohen LS, Wang B, Nonacs R, et al. Treatment of mood disorders during pregnancy and postpartum. Psychiatr Clin North Am. 2010;33(2):273-293.

Drug Brand Names

Bupropion • Wellbutrin, Zyban
Citalopram • Celexa
Desvenlafaxine • Pristiq
Duloxetine • Cymbalta
Escitalopram • Lexapro
Fluoxetine • Prozac
Fluvoxamine • Luvox
Mirtazapine • Remeron
Nefazodone • Serzone
Nortriptyline • Aventyl, Pamelor
Paroxetine • Paxil
Sertraline • Zoloft
Venlafaxine • Effexor

Dr. Freeman has received grant or research support from Eli Lilly and Company, Forest Laboratories, and GlaxoSmithKline, is on the advisory boards of Otsuka and Takeda/Lundbeck, and is a consultant for PamLab LLC.

Dr. Joffe has received grant or research support from Cephalon/Teva, and is a consultant to Noven and Sunovion.

Dr. Cohen has received research support from AstraZeneca, Bayer HealthCare Pharmaceuticals, Bristol-Myers Squibb, Forest Laboratories, GlaxoSmithKline, National Institute of Mental Health, National Institute on Aging, National Institutes of Health, Ortho-McNeil Janssen, and Pfizer and has served on an advisory board for PamLab LLC.