What is the treatment for postpartum depression?

Treatment of Postpartum Depression

Postpartum depression (PPD) requires a combination of psychotherapy and antidepressant medication for moderate to severe cases, with screening using the Edinburgh Postnatal Depression Scale (EPDS) as the first step in management. 1

Screening and Diagnosis

• The Edinburgh Postnatal Depression Scale (EPDS) is the recommended primary screening tool for PPD with class A recommendation based on adequate content validity and sufficient internal consistency 2, 1
• PPD affects approximately 15% of women during the first postpartum year 1
• Key risk factors to assess during screening:
  • Severe life events and chronic stress 2, 1
  • Poor relationship quality, especially with partner and mother 2, 1
  • Low levels of social support 1
  • History of mood or anxiety disorders (strongest risk factor) 3
  • Intimate partner violence or family conflict 1

Treatment Algorithm

Step 1: Assess Severity

• Use EPDS score to determine severity:
  • Mild: EPDS score 10-12
  • Moderate: EPDS score 13-16
  • Severe: EPDS score >16 or with suicidal/homicidal ideation

Step 2: Select Treatment Based on Severity

For Mild PPD:

• First-line: Individual or group-based interpersonal therapy 1
• Focus on role transitions and resolving interpersonal conflicts 1
• Consider telemental health options when in-person care is not accessible 2

For Moderate to Severe PPD:

• Combination therapy: Psychotherapy plus antidepressant medication 1, 4
• First-line antidepressant: Sertraline (Zoloft) due to minimal passage into breastmilk and decades of safety data 5, 4
• Alternative SSRIs: Paroxetine (Paxil) also shows undetectable infant serum levels 4
• For severe cases with psychosis: Immediate psychiatric referral 4

Step 3: Consider Emerging Treatments for Treatment-Resistant Cases

• Brexanolone (IV synthetic allopregnanolone) for rapid reduction in depressive symptoms 6
• Repetitive transcranial magnetic stimulation for women concerned about medication exposure during breastfeeding 4

Special Considerations

Breastfeeding Mothers

• Most antidepressants are considered compatible with breastfeeding 5
• Discuss with patient:
  • Benefits of breastfeeding
  • Risks of antidepressant use during lactation
  • Risks of untreated illness 4

Telemental Health Options

• Phone-based supportive interventions have shown efficacy in reducing PPD symptoms 2
• Consider virtual care options to enhance accessibility, particularly for mothers with barriers to in-person treatment 5

Common Pitfalls to Avoid

• Failing to distinguish between postpartum blues (first 10 days, self-resolving) and clinical PPD requiring intervention 1
• Overreliance on single-domain assessment tools rather than comprehensive evaluation 1
• Neglecting social support interventions as part of treatment 1
• Assuming PPD is solely due to hormonal changes rather than recognizing its complex biopsychosocial nature 1
• Delaying treatment, which can negatively impact maternal wellbeing and child cognitive, behavioral, and emotional development 6

Early identification and prompt treatment of PPD are essential for optimal maternal, infant, and family outcomes. The treatment approach should be guided by symptom severity, with psychotherapy as the foundation and medication added for moderate to severe cases.