Treatment of Postpartum Depression
For a postpartum woman with suspected postpartum depression, initiate cognitive behavioral therapy (CBT) immediately as first-line treatment, and add sertraline 25-50 mg daily if symptoms are moderate-to-severe or persist beyond 2 weeks of psychotherapy alone. 1, 2, 3
Screening and Diagnosis
Screen using the Edinburgh Postnatal Depression Scale (EPDS), which has 95% sensitivity and 93% specificity, with a score ≥10 indicating possible depression requiring further evaluation. 3, 4
Screening must be coupled with adequate systems for accurate diagnosis, effective treatment, and appropriate follow-up—screening alone without treatment infrastructure is insufficient. 1
Always assess for comorbid anxiety disorders, as they occur in approximately 16% of postpartum women and negatively impact treatment outcomes if unaddressed. 2, 3, 4
Screen for suicidal ideation immediately, as suicide is the second leading cause of maternal mortality in the United States. 3
Treatment Algorithm Based on Severity
Mild Depression (EPDS 9-13 or symptoms <2 weeks duration)
Monitor symptoms closely for 2 weeks while encouraging exercise and social support before initiating pharmacotherapy. 2
Initiate CBT or interpersonal psychotherapy (IPT) immediately rather than waiting—both have adequate evidence for improving clinical outcomes with minimal to no harms. 1, 2
If symptoms persist beyond 2 weeks or worsen during monitoring, add pharmacotherapy immediately—delaying treatment has significant negative consequences for maternal wellbeing and infant development. 2, 3
Moderate-to-Severe Depression (EPDS ≥10 or symptoms >2 weeks)
Initiate combination treatment with CBT plus sertraline, as this approach decreases clinical morbidity more effectively than either treatment alone. 2, 3
Start sertraline 25-50 mg daily for moderate depression (EPDS 10-14) or 50 mg daily for severe depression (EPDS ≥15), titrating based on response. 4, 5
Sertraline is the preferred first-line antidepressant due to minimal passage into breast milk and decades of safety data, with paroxetine as the alternative option. 2, 3, 5
Psychotherapy Specifics
CBT focuses on behavioral activation, cognitive restructuring, and problem-solving skills, addressing both biological and psychosocial factors contributing to the condition. 1
IPT focuses on navigating role transitions and resolving conflicts with close others, which has shown moderate success in reducing postpartum depression. 2
Telemental health may be superior to in-person treatment, with mean EPDS score reductions of 2.99 points (95% CI -4.52 to -1.46) compared to usual care, offering increased accessibility. 2
Pharmacotherapy Details
Sertraline transfers to breast milk in lower concentrations than other antidepressants, making it the preferred option for breastfeeding mothers. 2, 5
The risks of untreated maternal depression generally outweigh the minimal risks of antidepressant exposure through breastmilk, as untreated depression impairs maternal-infant bonding and adversely affects infant cognitive and emotional development. 3, 4
Do not stop sertraline abruptly—taper gradually to avoid withdrawal symptoms including anxiety, irritability, electric shock-like sensations, and confusion. 5
Avoid sertraline if the patient takes MAOIs, pimozide, or disulfiram (if using liquid formulation due to alcohol content). 5
Critical Pitfalls to Avoid
Never delay treatment beyond 2 weeks if symptoms persist or worsen—the consequences of untreated depression for both mother and infant development are substantial and long-lasting. 2, 3
Do not overlook comorbid anxiety disorders, which frequently co-occur with postpartum depression and require comprehensive treatment approaches. 2, 3
Do not neglect to involve family support systems—partner and family support are consistently protective factors, and leveraging existing support is crucial for recovery. 2
Never assume mild symptoms will resolve spontaneously without monitoring—depression prevalence peaks at 12 weeks postpartum (17.4%) and continues rising through the first year. 4
Follow-Up and Monitoring
Schedule follow-up within 1-2 weeks after initiating or changing medication to assess symptom improvement and adjust treatment. 3
Monitor monthly during the first 3 months of treatment, then every 2-3 months if stable, as ongoing surveillance is essential given the rising prevalence through the first postpartum year. 4
If breastfeeding on medications, monitor infant development carefully for appropriate weight gain and developmental milestones. 3
Reassess treatment if no improvement after 4-6 weeks—consider increasing dose, switching medications, or intensifying psychotherapy. 2