Postpartum Depression: Screening and Treatment Approach
Use the Edinburgh Postnatal Depression Scale (EPDS) as your primary screening tool, with a cutoff score ≥10 indicating possible depression requiring further evaluation. 1, 2
Screening Protocol
The EPDS is the gold standard screening instrument for postpartum depression, receiving a Class A recommendation based on superior psychometric properties including adequate content validity and sufficient internal consistency with structural validity. 1 This 10-item questionnaire evaluates symptoms over the past 7 days, with scores ranging from 0-30. 1
Specific Cutoff Scores and Actions:
- Score ≥10: Possible depression—requires clinical interview and further assessment 1, 2
- Score ≥13: Probable depression—initiate treatment planning 1
- Any positive response to question 10 (thoughts of self-harm): Immediate safety assessment required 2
The PHQ-9 is an acceptable alternative screening tool, though the EPDS has stronger validation specifically for postpartum populations. 1, 2, 3 When both tools are used, concordance occurs in approximately 83% of cases. 3
Critical Screening Pitfall:
Document suicidal ideation explicitly in your clinical note, as this is frequently captured on screening tools but underreported in clinical documentation. 2
Comprehensive Clinical Assessment
Beyond the screening score, assess these specific domains:
- Comorbid anxiety symptoms: These co-occur frequently with postpartum depression and negatively impact treatment outcomes if unaddressed 2, 4
- Sleep disturbance patterns: Distinguish between infant-related sleep disruption versus insomnia independent of infant needs
- Thoughts of infant harm: Assess both passive thoughts and active intent
- Current therapy engagement: Document frequency, type, and perceived effectiveness 2
- Breastfeeding status: Critical for medication selection 4, 5
Treatment Algorithm Based on Severity
Mild Symptoms (EPDS 9-13):
Initiate cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) immediately rather than adopting a "watchful waiting" approach. 4 Phone-based interventions are effective, reducing EPDS scores by 1.18-2.18 points compared to usual care. 4
Moderate-to-Severe Symptoms (EPDS ≥14) or Persistent Mild Symptoms Beyond 2 Weeks:
Initiate combination treatment with psychotherapy plus pharmacotherapy. 4
Pharmacotherapy Recommendations
For breastfeeding women, sertraline is the first-line antidepressant due to minimal passage into breast milk and decades of safety data. 4, 5 Paroxetine is the alternative first-line option. 4
Key Medication Principles:
- Most SSRIs are compatible with breastfeeding 5, 6
- Initiate pharmacotherapy immediately if symptoms persist beyond 2 weeks from diagnosis or worsen during monitoring 4
- For confirmed bipolar disorder, lamotrigine is the safest traditional mood stabilizer during breastfeeding, though data is limited 4
Critical Treatment Pitfall:
Do not delay treatment beyond 2 weeks if symptoms persist or worsen. Untreated postpartum depression has significant negative consequences for maternal wellbeing, infant development, and mother-infant bonding. 4 Remember that suicide is the second leading cause of maternal mortality in the United States. 1, 4
Follow-Up and Monitoring
Schedule follow-up within 1-2 weeks after initiating or changing any treatment to assess symptom improvement and adjust the treatment plan. 4 Use the EPDS or PHQ-9 at each visit to track treatment response quantitatively. 2
Document at each visit:
- Current depression severity using validated screening scores 2
- Safety concerns and update safety plan if indicated 2
- Clear follow-up plan with scheduled reassessment 2
- If breastfeeding on medications, monitor infant weight gain and developmental milestones 4
Special Considerations
Approximately 10% of adults with recurrent depression have comorbid ADHD that must be addressed for optimal outcomes. 4 Screen for this if treatment response is suboptimal.
The prevalence of postpartum depression is approximately 15% during the first postpartum year. 1, 4 Your clinical threshold for screening should be low, as early diagnosis and treatment minimize disease severity and associated morbidity. 1