What is the first line treatment for a woman with perinatal depression?

First-Line Treatment for Perinatal Depression

For mild-to-moderate perinatal depression, psychotherapy—specifically cognitive behavioral therapy (CBT) or interpersonal therapy (IPT)—is the first-line treatment, while moderate-to-severe depression requires combining psychotherapy with antidepressants, preferably sertraline. 1, 2

Treatment Algorithm Based on Severity

Mild Depression (Recent Onset ≤2 Weeks)

• Begin with monitoring and supportive measures including encouraging exercise and social support before initiating pharmacological treatment 1
• If symptoms persist beyond 2 weeks or worsen during monitoring, immediately escalate to evidence-based treatment 1, 2
• Do not delay treatment beyond 2 weeks as untreated depression has significant negative consequences for both maternal wellbeing and infant development 2

Mild-to-Moderate Depression

• Psychotherapy is first-line treatment 1, 3, 4
• Cognitive behavioral therapy (CBT) is equally effective as antidepressants and should be the initial approach 1, 2
• Interpersonal therapy (IPT) focusing on role transitions and resolving conflicts with close others has shown moderate success 2
• Both therapies have adequate evidence for improving clinical outcomes with minimal harms 2, 5

Moderate-to-Severe Depression

• Combination therapy with both psychotherapy and antidepressants provides optimal outcomes and decreases clinical morbidity more effectively than either treatment alone 2, 5, 4
• Sertraline is the preferred antidepressant when pharmacotherapy is needed 1, 2, 5
• Sertraline transfers to breast milk in lower concentrations than other antidepressants, making it the safest option for breastfeeding mothers 1, 2

Antidepressant Selection for Perinatal Use

During Pregnancy

• SSRIs are the most commonly prescribed antidepressants for pregnant women 1
• Sertraline, citalopram, and escitalopram appear safest during pregnancy 5
• Consider antidepressants for women with history of severe suicide attempts, severe depression with good prior medication response, or previous relapse when discontinuing treatment 1

During Breastfeeding

• Sertraline and paroxetine are preferred as they lead to the lowest serum medication levels in breastfed infants 1, 2, 5
• Undetectable infant serum levels have been demonstrated with sertraline in pooled case reports 4

Risk-Benefit Considerations

Risks of Untreated Depression

• Untreated depression is associated with premature birth and decreased initiation of breastfeeding 1
• Negative impacts on infant development including cognitive, behavioral, and emotional delays 2, 3
• Impaired mother-infant bonding and increased risk of behavioral problems in the child's later life 3

Risks of Antidepressant Treatment

• Antidepressant use during pregnancy may increase risk of preterm delivery compared to untreated women with depression 1
• Neonatal adaptation syndrome occurs in approximately 30% of third-trimester SSRI exposures, with symptoms including crying, irritability, tremors, poor feeding, hypertonia, and tachypnea, but is typically self-limiting and resolves within 1-4 weeks 1
• A meta-analysis found a link between late pregnancy SSRI exposure and persistent pulmonary hypertension of the newborn (PPHN) with a number needed to harm of 286-351 1
• Recent evidence provides reassurance that antidepressant use during pregnancy is unlikely to substantially increase risk of autism spectrum disorder or ADHD 1

Critical Pitfalls to Avoid

• Do not delay treatment beyond 2 weeks if symptoms persist or worsen during initial monitoring 2
• Do not fail to screen for comorbid anxiety disorders, which frequently co-occur with perinatal depression and can negatively impact treatment outcomes 2
• Do not advise stopping antidepressants without careful risk-benefit analysis, as the majority of women who discontinue antidepressants during the perinatal period suffer from relapsing symptoms 3
• Do not overlook the importance of family support systems, as partner and family support are consistently protective factors against postpartum depression 2
• The risks of untreated maternal depression generally outweigh the minimal risks of antidepressant exposure through breastmilk 2

Alternative and Adjunctive Approaches

• Telemental health may be superior to treatment as usual for reducing postpartum depression symptoms, offering increased accessibility 2
• Dialectical Behavior Therapy (DBT) can be beneficial, particularly for those with comorbid conditions 2
• Mindfulness-based interventions can improve self-compassion and parental self-efficacy 2
• For severe cases with psychosis, suicidal ideation, or thoughts of harming the infant, immediate psychiatric consultation and possible inpatient treatment are required 5, 4