What is the recommended treatment for a postpartum woman with depression, considering breastfeeding status and potential severe symptoms?

Postpartum Depression Treatment

Start sertraline 25-50 mg daily as first-line treatment for postpartum depression, regardless of breastfeeding status, and titrate to a maximum of 200 mg/day based on clinical response. 1, 2

Initial Assessment

Before initiating treatment, evaluate the following:

• Depression severity using the Edinburgh Postnatal Depression Scale (EPDS): Scores ≥10 indicate possible depression requiring treatment (95% sensitivity, 93% specificity) 2
• Thyroid function: Postpartum thyroiditis affects 5-7% of women in the first year after delivery with symptoms that overlap substantially with depression 2
• Anemia status: Common postpartum and contributes to fatigue and mood symptoms 2
• Suicidal ideation: Screen at every visit, as risk is highest in the first few months of treatment or with dose changes 2

Treatment Algorithm by Severity

Moderate to Severe Depression

• Initiate sertraline 25-50 mg daily as the preferred SSRI, with minimal breast milk transfer and decades of safety data 1, 2
• Combine with cognitive behavioral therapy for optimal outcomes 2
• Titrate weekly by 25-50 mg increments to a maximum of 200 mg/day based on clinical response 1, 3
• Sertraline transfers into breast milk in the lowest concentrations among SSRIs and produces undetectable infant plasma levels at all therapeutic doses 1

Alternative Antidepressants

If sertraline is not tolerated or effective:

• Paroxetine: Second-line option with minimal breast milk transfer, similar safety profile to sertraline 1, 2
• Bupropion: Consider for comorbid conditions (e.g., co-occurring depression with other psychiatric conditions), present in human milk at very low or undetectable levels in infant serum 1
• Avoid fluoxetine as first-line: Produces the highest infant plasma concentrations among SSRIs and has been associated with more frequent reports of suspected adverse effects in infants 1
• Use citalopram with caution: Produces higher infant plasma levels and has been associated with nonspecific adverse effects (irritability, decreased feeding) more often than sertraline or paroxetine 1

Breastfeeding Management

For Mothers on Sertraline or Paroxetine

• Maintain therapeutic dose at the time of delivery and during breastfeeding without dose adjustment 1, 2
• No need for timing of feeds or pumping due to minimal milk transfer 1

For Mothers on Other SSRIs or Bupropion

• Monitor infant development carefully for irritability, excessive crying, poor feeding, unusual drowsiness, sleep disturbances, adequate weight gain, and developmental milestones 1
• Consider timing feeding or pumping to achieve lowest concentration in breast milk if using medications with higher transfer rates 1

Treatment Duration and Follow-Up

• Schedule reassessment at 2-4 weeks after initiation to evaluate response and side effects 2
• Continue treatment for 4-12 months minimum for a first episode of major depression 2
• Extend treatment duration indefinitely for women with recurrent depression or multiple prior episodes 2
• Screen for suicidal ideation at every visit 2

Evidence Quality and Clinical Context

The evidence supporting sertraline's efficacy comes from randomized controlled trials showing significantly greater response rates (59% vs. 26% placebo) and remission rates (53% vs. 21% placebo), with effects most pronounced in women with depression onset within 4 weeks of childbirth 4. A Cochrane systematic review found low-certainty evidence that SSRIs may be more effective than placebo, though the evidence base remains limited 5. Despite this, sertraline's extensive safety data in breastfeeding, with consistently undetectable infant plasma levels and no adverse effects reported, makes it the clear first-line choice 1, 2.

Common Pitfalls to Avoid

• Do not discontinue abruptly: Stopping sertraline too quickly may cause withdrawal symptoms including anxiety, irritability, mood changes, restlessness, sleep changes, headache, sweating, nausea, dizziness, and electric shock-like sensations 3
• Do not delay treatment due to breastfeeding concerns: The risks of untreated postpartum depression to mother and infant outweigh the minimal risks of sertraline exposure through breast milk 1, 2
• Do not use fluoxetine as first-line in breastfeeding mothers: One case report documented measurable plasma fluoxetine levels and substantial decline in platelet serotonin (to 40% of baseline) in a breastfed infant, though this resolved when drug levels became undetectable 6