What is the best diagnosis and medication to consider for a postpartum (postpartum, after childbirth) patient experiencing mood swings and irritability?

Postpartum Depression: Diagnosis and Treatment

The most likely diagnosis is postpartum depression (PPD), and sertraline is the first-line medication to consider, started at the lowest effective dose while continuing breastfeeding if applicable. 1, 2

Diagnostic Approach

Screen using the Edinburgh Postnatal Depression Scale (EPDS), which is the most robustly validated screening tool for postpartum depression with translations in over 60 languages and demonstrated criterion validity. 1

• A cutoff score of 11 or higher on the EPDS maximizes combined sensitivity and specificity for detecting PPD 1
• The EPDS consists of 10 questions yielding a total score between 0-30, with lower scores indicating less depression 1
• Screening should occur because PPD affects 10-15% of new mothers, with meta-analyses estimating prevalence at 19.2% for minor and 7.1% for major PPD within three months after delivery 1, 3

Confirm diagnosis using DSM-5 criteria for major depressive disorder with peripartum onset, which specifies symptom onset during pregnancy or within the first four weeks postpartum (though research definitions extend up to one year). 1

Key symptoms to assess include:

• Depressed mood, crying spells, irritability 4
• Insomnia, fatigue, poor concentration 4
• Anxiety, feelings of worthlessness 4
• Duration of at least two weeks with significant functional impairment 1

Critical risk factors to identify:

• History of depression or other affective illness (strongest predictor) 4, 5
• Active mood or anxiety symptoms during pregnancy 5
• History of depression during previous pregnancies 1
• Psychosocial stressors including lack of social support 1

Treatment Algorithm

First-Line Pharmacotherapy: Sertraline

Initiate sertraline as the preferred SSRI for postpartum women, particularly those who are breastfeeding, due to minimal passage into breastmilk and decades of safety data. 2

Starting dose and titration:

• Begin with the lowest effective dose 6, 7
• Standard starting dose is typically 25-50 mg daily, titrated based on response 7
• Continue treatment for 6-12 months postpartum to ensure complete recovery and prevent recurrence 4

Critical counseling points for sertraline:

• Continue medication during pregnancy and postpartum rather than discontinuing, as withdrawal may have harmful effects on the mother-infant dyad 6
• Most antidepressants, including sertraline, are compatible with breastfeeding 6, 2
• Neonates exposed to sertraline in late third trimester may develop transient neonatal adaptation syndrome with symptoms including crying, irritability, tremors, poor feeding, hypertonia, tachypnea, sleep disturbance, and rarely hypoglycemia or seizures 1, 6
• These neonatal symptoms typically resolve within 1-4 weeks and are generally mild 1, 6
• Multiple reviews have not identified adverse neurodevelopmental outcomes in infants exposed to SSRIs during pregnancy 6

Monitor for serious adverse effects:

• Suicidal thoughts or actions, especially in the first few months of treatment or with dose changes 7
• Serotonin syndrome (agitation, hallucinations, tachycardia, hyperthermia, muscle rigidity, nausea) 7
• Abnormal bleeding risk, particularly if taking NSAIDs, aspirin, or warfarin 7

Psychotherapy

Combine medication with evidence-based psychotherapy for optimal outcomes, as psychological treatments are effective and preferred by many perinatal patients. 2

Recommended modalities include:

• Interpersonal therapy 4
• Short-term cognitive-behavioral therapy 4
• Supportive counseling 1

Monitoring Requirements

Arrange early follow-up after delivery if the patient was treated with sertraline in the third trimester, as infants are at risk for withdrawal or toxicity symptoms over the first week of life. 6

Monitor the infant carefully for:

• Irritability, insomnia, feeding difficulty 1, 6
• Respiratory symptoms 6

Inform the pediatric team about maternal sertraline use so they can anticipate and manage neonatal adaptation syndrome if it occurs. 6

Important Clinical Pitfalls

Do not abruptly discontinue sertraline, as this can cause withdrawal symptoms including anxiety, irritability, mood changes, restlessness, sleep disturbances, headache, sweating, nausea, dizziness, and electric shock-like sensations. 7

Do not confuse PPD with other postpartum conditions:

• Postpartum blues (milder, self-limited symptoms in first 2 weeks) is a risk factor for PPD but distinct from it 1
• ADHD symptoms (inattention, hyperactivity-impulsivity) may worsen postpartum but require different diagnostic criteria and treatment 1

Inadequate treatment puts women at risk for chronic, recurrent, or refractory depression, and adversely affects infant cognitive, behavioral, and emotional development with effects potentially lasting into adolescence. 1, 4