What is the recommended screening and treatment approach for postpartum depression (PPD)?

Postpartum Depression Screening and Management

Recommended Screening Tool

The Edinburgh Postnatal Depression Scale (EPDS) is the gold standard screening tool for postpartum depression and should be used as the primary screening instrument. 1, 2

Why the EPDS is Superior

• The EPDS received a Class A recommendation (the highest level) in a 2022 JAMA Network Open systematic review that evaluated 10 validated screening tools across 43 studies involving 22,095 postpartum women 1
• It is the only screening tool with sufficient structural validity and internal consistency, demonstrating adequate content validity with moderate-level evidence 1
• The EPDS has demonstrated sensitivity of 95% and specificity of 93% compared to DSM-III criteria 1
• It is available in over 60 languages, making it culturally adaptable 3

How to Use the EPDS

• The EPDS consists of 10 questions evaluating symptoms over the past 7 days 2
• Scores range from 0-30, with scores ≥10 indicating possible depression requiring further evaluation 1, 2
• A cutoff score of 11 or higher maximizes combined sensitivity and specificity for detecting postpartum depression 3
• Administer at the initial postpartum encounter and at regular intervals during the first postpartum year 2
• The EPDS can be administered by telephone at 6-8 weeks postpartum as an efficient and accurate screening method 4

Alternative Screening Options

• The Patient Health Questionnaire-9 (PHQ-9) is an acceptable alternative that can assess current depression severity and treatment response 2
• However, the PHQ-9 performs significantly less accurately than the EPDS, with sensitivity of only 31-48% compared to the EPDS's 62% at comparable cutoff points 4
• The Postpartum Depression Screening Scale (PDSS) with a cutoff of ≥80 has sensitivity of 94% and specificity of 98%, but requires purchase for use and is less widely validated 1
• The 3-item anxiety subscale of the EPDS (EPDS-3) shows promise as an ultrabrief screener with 95% sensitivity and 98% negative predictive value, though it requires validation by diagnostic psychiatric interview 5

Clinical Assessment Components

Essential Documentation

• Document current depression severity using validated screening tool scores at each encounter 2
• Carefully document any suicidal ideation, as this is frequently underreported in clinical documentation despite being captured on screening tools 2
• Record therapy engagement, frequency, and perceived effectiveness if the patient is receiving psychotherapy 2

Comorbidity Screening

• Screen for comorbid anxiety symptoms, which commonly co-occur with postpartum depression 2
• Anxiety is a more prominent feature of postpartum depression than depression occurring at other times in life 5
• Postpartum depression frequently co-occurs with other psychiatric disorders, most commonly anxiety disorders 1

Risk Factor Assessment

• History of depression during previous pregnancies is a critical risk factor to identify 3
• The strongest risk factor is a history of mood or anxiety disorder, especially having active symptoms during pregnancy 6
• Assess psychosocial stressors, including lack of social support 3

Diagnostic Confirmation

Formal Diagnosis Criteria

• Confirm diagnosis using DSM-5 criteria for major depressive disorder with peripartum onset 3
• Symptom onset must occur during pregnancy or within the first four weeks postpartum per DSM-5 criteria 3
• Duration of symptoms should be at least two weeks with significant functional impairment 3
• The gold standard for diagnosing postpartum depression is a clinical interview, most notably the Structured Clinical Interview for the DSM-IV 1

Prevalence and Timing

• Postpartum depression affects 10-15% of new mothers 1, 3
• Meta-analyses estimate prevalence at 19.2% for minor and 7.1% for major postpartum depression within three months after delivery 1, 3
• Associations between biological measures and postpartum depression are more likely to be detected when symptoms are assessed earlier in the postpartum period (within the first 3 months) 1

Treatment Approach

First-Line Pharmacotherapy

• 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 3
• Start with the lowest effective dose, typically 25-50 mg daily, titrated based on response 3
• Most antidepressants, including sertraline, are compatible with breastfeeding 3
• Multiple reviews have not identified adverse neurodevelopmental outcomes in infants exposed to SSRIs during pregnancy 3

Neonatal Considerations

• Neonates exposed to sertraline in late third trimester may develop transient neonatal adaptation syndrome 3
• Symptoms include crying, irritability, tremors, poor feeding, hypertonia, tachypnea, sleep disturbance, and rarely hypoglycemia or seizures 3
• These symptoms typically resolve within 1-4 weeks and are generally mild 3
• 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 3

Monitoring Requirements

• Monitor the infant carefully for irritability, insomnia, feeding difficulty, and respiratory symptoms 3
• Inform the pediatric team about maternal sertraline use so they can anticipate and manage neonatal adaptation syndrome if it occurs 3
• Create a clear follow-up plan with scheduled reassessment of depression symptoms 2
• Document any safety concerns and create a safety plan if indicated 2

Critical Pitfalls to Avoid

Medication Management Errors

• Never 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 3

Diagnostic Confusion

• Postpartum blues is distinct from postpartum depression, with symptoms typically resolving within two weeks 3
• ADHD symptoms may worsen postpartum but require different diagnostic criteria and treatment 3

Consequences of Inadequate Treatment

• Inadequate treatment puts women at risk for chronic, recurrent, or refractory depression 3
• Untreated postpartum depression adversely affects infant cognitive, behavioral, and emotional development, with effects potentially lasting into adolescence 1, 3

Cultural Considerations

• Postpartum depression prevalence ranges from almost nonexistent to well above 50% across different cultures 1
• Cultural factors include dietary proscriptions, sources and types of stress, social support, parental gender roles, religious customs, and attitudes about mental health 1
• Protective factors such as cultural rituals that help mothers (e.g., family support over the first month postpartum) can delay symptom onset and reduce rates 1