From the Guidelines
Postpartum depression is typically treated with a combination of psychotherapy and medication, with selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) being highly effective options. The treatment approach should prioritize the patient's safety, particularly for breastfeeding mothers, and consider the potential risks and benefits of each treatment option 1.
Treatment Options
- First-line medications include SSRIs such as sertraline (starting at 50mg daily, increasing to 100-200mg as needed), fluoxetine (20-60mg daily), or escitalopram (10-20mg daily) 1.
- Cognitive behavioral therapy (CBT) or interpersonal therapy (IPT), typically delivered in 12-16 weekly sessions, is highly effective either alone or combined with medication 1.
- Support groups, regular exercise, adequate sleep, and enlisting help with childcare are important complementary approaches.
- For severe cases with suicidal thoughts or psychosis, immediate psychiatric evaluation is necessary, sometimes requiring hospitalization.
Considerations for Breastfeeding Mothers
- Breastfeeding mothers can generally take SSRIs, as most have minimal presence in breast milk, but this should be discussed with a healthcare provider 1.
- The Edinburgh Postnatal Depression Scale (EPDS) is a useful tool for screening for postpartum depression, with good psychometric properties and cross-cultural validity 1.
Importance of Integrated Care
- Postpartum depression results from a combination of hormonal fluctuations after childbirth, sleep deprivation, and the psychological adjustment to motherhood, making a multifaceted treatment approach necessary for recovery 1.
- Clinicians should consider the biopsychosocial factors associated with postpartum depression, including hypothalamic-pituitary-adrenal dysregulation, inflammatory processes, and genetic vulnerabilities, as well as psychosocial factors such as severe life events, relationship quality, and support from partner and mother 1.
From the Research
Treatment Options for Postpartum Depression (PPD)
The treatment options for PPD include:
- Pharmacological treatments:
- Selective serotonin reuptake inhibitors (SSRIs) such as sertraline are generally the first-line antidepressant medication recommended to women in the postpartum period due to their minimal passage into breastmilk and corresponding safety data 2, 3, 4
- Neurosteroids are emerging as an effective treatment for postpartum depression, although currently this treatment is not widely available 2
- Psychological treatments:
- Psychotherapy is effective and preferred by many perinatal patients over medications, but it often remains inaccessible 2
- Psychotherapy is the first-line treatment option for women with mild to moderate peripartum depression 3
- Evidence-based psychotherapy can be used in combination with antidepressant medication for women with moderate to severe depression 3
- Non-pharmacologic interventions:
- Repetitive transcranial magnetic stimulation may offer an attractive option for women who wish to continue to breastfeed and are concerned about their infants being exposed to medication 3
- Virtual care, task-sharing to non-specialist treatment providers, and collaborative care models are potential solutions to enhance the reach and scalability of effective treatments 2
Barriers to Treatment
Barriers to widespread access to treatment include:
- Systematic barriers: lack of specialist providers 2
- Provider-driven barriers: lack of flexibility in treatment delivery 2
- Patient-driven barriers: stigma and lack of time for treatment engagement 2
Safety of Antidepressants During Breastfeeding
Most antidepressant drugs are considered compatible with breastfeeding 2, 3, but further research is needed to understand the safety of antidepressant use during lactation, including larger samples and long-term follow-up of infants exposed to antidepressants via breastfeeding 3, 4