What is the next step for a 32-year-old postpartum patient with no psychiatric history, presenting with symptoms of depression 6 weeks after giving birth and an Edinburgh Postnatal Depression Scale (EPDS) score of 20?

Management of Postpartum Depression with EPDS Score of 20

The next step for this 32-year-old patient with an EPDS score of 20 at 6 weeks postpartum should be to initiate treatment with an antidepressant.

Assessment of Current Presentation

The patient presents with:

• 32 years old, first-time mother
• 6 weeks postpartum
• No prior psychiatric history
• EPDS score of 20 (indicating severe depression)

An EPDS score of 20 is significantly above the standard cutoff of ≥10 for possible depression 1. According to evidence-based guidelines, this score indicates severe postpartum depression requiring immediate intervention rather than further screening or monitoring.

Rationale for Immediate Treatment

1. Severity of symptoms: An EPDS score of 20 falls into the range indicating severe depression, which warrants prompt treatment rather than watchful waiting or additional screening.

2. Timing of presentation: At 6 weeks postpartum, this represents established postpartum depression rather than transient "baby blues," which typically resolve within 2 weeks after delivery.

3. Risk of progression: Untreated postpartum depression can have substantial adverse effects on:

   • Maternal well-being
   • Mother-infant bonding
   • Child cognitive, behavioral, and emotional development with lasting consequences 2

Why Additional Screening is Not Indicated

• Re-administering EPDS at 1 month postpartum (Option A) would unnecessarily delay treatment for a patient already showing clear signs of depression with a high EPDS score.

• Administering a (hypo)mania screening tool (Option B) would be appropriate if there were specific concerns about bipolar disorder, but the clinical scenario does not suggest manic or hypomanic symptoms. The primary presentation is depressive symptoms in a patient with no psychiatric history.

Treatment Approach

Initiating treatment with an antidepressant (Option C) is appropriate because:

1. Evidence supports pharmacotherapy: Antidepressants are effective for treating postpartum depression 3.

2. Sertraline as first-line: Among pharmacological treatments, sertraline is generally the first-line antidepressant recommended for women in the postpartum period due to minimal passage into breastmilk and decades of safety data 3.

3. Rapid intervention needed: The high EPDS score (20) indicates severe depression requiring prompt intervention to reduce morbidity and improve quality of life.

Important Clinical Considerations

• Suicide risk assessment: The EPDS includes items assessing suicidal ideation, and with a score of 20, careful evaluation of suicide risk is essential 4.

• Breastfeeding status: Most antidepressants are considered compatible with breastfeeding 3, but this should be discussed with the patient.

• Psychotherapy: While initiating an antidepressant is the appropriate next step, evidence-based psychotherapy (particularly cognitive-behavioral therapy) should also be considered as part of the treatment plan 3.

• Follow-up: Close monitoring is essential during the initial weeks of treatment to assess response and adjust the approach as needed.

By initiating treatment with an antidepressant now rather than delaying with additional screening, you can address this patient's significant depressive symptoms and reduce the risk of adverse outcomes for both mother and child.