What is the recommended treatment for postpartum anxiety?

Treatment of Postpartum Anxiety

For women with postpartum anxiety, first-line treatment should include cognitive behavioral therapy (CBT), with selective serotonin reuptake inhibitors (SSRIs) recommended for moderate to severe cases or when psychotherapy alone is insufficient. 1

Assessment and Diagnosis

• Use validated screening tools to assess postpartum anxiety:

  • Generalized Anxiety Disorder-7 (GAD-7) scale: scores 0-4 (minimal), 5-9 (mild), 10-14 (moderate), 15-21 (severe) 1
  • Edinburgh Postnatal Depression Scale (EPDS): can detect anxiety with moderate accuracy (area under ROC curve 0.62-0.73) 2

• Risk factors to assess:

  • History of depression or anxiety 3
  • Low maternal self-efficacy 3
  • Poor maternal health 3
  • Negative delivery experience 3
  • Low partner support 3
  • Excessive infant crying 3

Treatment Algorithm

Step 1: Non-Pharmacological Interventions (First-Line)

• Cognitive Behavioral Therapy (CBT): First-line treatment with demonstrated effectiveness and minimal adverse effects 1

  • Focus on addressing excessive worry, catastrophizing, and anxiety-related behaviors
  • Include partner involvement when possible

• Self-management strategies:

  • Psychoeducation about postpartum anxiety
  • Physical activity: Regular exercise helps reduce anxiety symptoms 2
  • Limit sedentary behavior: Break up sitting time with short activity periods 2
  • Ensure adequate sleep when possible

Step 2: Pharmacological Treatment (For Moderate to Severe Cases)

SSRIs are the first-line medication for moderate to severe postpartum anxiety:

• Sertraline (preferred option):

  • Start at 25mg daily for one week 1, 4
  • Increase to 50mg daily after the first week 1
  • May increase gradually to maximum 200mg daily if needed 1
  • Most patients respond to 50-100mg daily 1
  • Safe during breastfeeding with minimal infant exposure 4
  • Demonstrated efficacy in postpartum depression with 59% response rate vs 26% for placebo 5

• Alternative SSRIs:

  • Fluoxetine: Start at 10mg daily 1
  • Escitalopram: Start at 5mg daily, may increase to 10-20mg

• SNRIs (second-line):

  • Venlafaxine: Consider if SSRIs are ineffective or not tolerated 1

Breastfeeding Considerations

• Sertraline is one of the safest antidepressants during breastfeeding 4
• Recommendations for breastfeeding mothers on medication:
  • Use lowest effective dose 4
  • Monitor infant for irritability, poor feeding, or sleep disturbances 4
  • When possible, time breastfeeding to avoid peak medication concentration in milk 4
  • Continue breastfeeding if already on sertraline before delivery 4

Follow-up and Monitoring

• Schedule follow-up within 1-2 weeks of initiating treatment 1

• Monitor for:

  • Treatment response using GAD-7 or EPDS
  • Side effects of medication (dry mouth, nausea, diarrhea, headache, insomnia)
  • Worsening anxiety or emergence of suicidal thoughts 1
  • Infant well-being if breastfeeding while on medication 4

• Continue treatment for at least 9-12 months after symptom remission 1

Special Considerations

• Severe symptoms or postpartum psychosis: Hospitalization may be required to ensure safety 6
• Comorbid depression: Common (56% of patients with depression have anxiety) and may require adjusted treatment approach 1
• Thyroid dysfunction: Consider screening as thyroid abnormalities can contribute to mood and anxiety symptoms postpartum 6

Emerging Preventive Approaches

• Internet-delivered prevention programs like "Preventing Postpartum Onset Distress" (P-POD) show promise for at-risk pregnant women 7
• These programs provide educational modules teaching CBT skills for anxiety management 7

Remember that postpartum anxiety is common (prevalence 9.3-16%) 2 and early intervention can significantly improve outcomes for both mother and infant.