How should I screen and manage postpartum depression in a breastfeeding woman who delivered within the past year and presents with persistent low mood, loss of interest, anxiety, irritability, insomnia or hypersomnia, guilt, hopelessness, or thoughts of harming herself or her baby?

Screening and Management of Postpartum Depression in Breastfeeding Women

Immediate Screening Approach

Use the Edinburgh Postnatal Depression Scale (EPDS) as your primary screening tool—it has 95% sensitivity and 93% specificity and is the best validated instrument for postpartum depression screening. 1, 2, 3

How to Screen

• Administer the EPDS after 2 weeks postpartum (not earlier, as postpartum blues typically resolves by then) 2, 4
• A score ≥10 indicates possible depression requiring further clinical evaluation 2, 3
• A score ≥11 maximizes combined sensitivity and specificity 1, 2
• The EPDS evaluates symptoms over the past 7 days and is available in over 60 languages 2
• Critical distinction: The EPDS screens for risk but does NOT diagnose—you must conduct a clinical interview using DSM-5 criteria to establish the diagnosis 3

Diagnostic Confirmation

• Conduct a structured clinical interview to confirm major depressive disorder with peripartum specifier 3
• Diagnosis requires at least 2 weeks of depressive symptoms causing significant functional impairment 1, 3
• Screen concurrently for anxiety disorders, which co-occur in approximately 16% of postpartum women and affect treatment outcomes 3

Risk Stratification

Highest Risk Factors to Assess

The strongest predictors of postpartum depression include: 1, 2

• History of depression or anxiety (strongest predictor) 3, 5
• Severe recent life events
• Chronic strain or poor relationship quality
• Lack of support from partner or mother
• Active mood/anxiety symptoms during pregnancy 5

Management Algorithm

For Positive Screen (EPDS ≥10) Without Immediate Safety Concerns

Step 1: Assess Severity and Safety

• Evaluate for suicidal or homicidal ideation—if present, initiate immediate psychiatric evaluation and safety planning 2
• Assess functional impairment in self-care and infant care—if significant, requires immediate intervention 2

Step 2: Initiate Treatment Based on Severity

Mild Depression (EPDS 10-12, minimal functional impairment):

• Start cognitive behavioral therapy (CBT) as first-line monotherapy 2
• Provide psychoeducation about postpartum depression 2
• Arrange follow-up within 1-2 weeks 2

Moderate-to-Severe Depression (EPDS ≥13 or significant functional impairment):

• Initiate sertraline 25-50 mg daily PLUS CBT for optimal outcomes 2
• Sertraline is the preferred SSRI for breastfeeding women due to minimal passage into breastmilk and decades of safety data 2
• Consider interpersonal therapy focusing on role transitions and relationship conflicts as an alternative or adjunct to CBT 2

Follow-Up Schedule

• Reassess within 1-2 weeks (at 3-4 weeks postpartum) using repeat EPDS scoring 2
• Continue surveillance throughout the first year, as depression prevalence peaks at 12 weeks (17.4%) and continues rising 2, 3
• Schedule structured follow-up appointments rather than relying on patient-initiated contact 2

Critical Pitfalls to Avoid

Timing Errors

• Do not screen before 2 weeks postpartum—postpartum blues (affecting majority of mothers) typically resolves within 10-14 days and does not require treatment 2, 3
• Do not rely solely on early postpartum screening—depression prevalence increases substantially over the first 12 weeks and throughout the first year 2, 3

Diagnostic Confusion

• Do not confuse postpartum blues with postpartum depression—blues is self-limited and resolves within 2 weeks, while depression requires minimum 2 weeks of symptoms with functional impairment 2, 3
• Do not assume screening tools provide diagnosis—clinical interview remains mandatory 3

Treatment Gaps

• Do not overlook comorbid anxiety disorders—they occur frequently and require concurrent treatment 3
• Do not delay treatment in breastfeeding women due to medication concerns—sertraline has extensive safety data and minimal infant exposure 2
• Do not assume "normal grief" will resolve without intervention in women with severe precipitating stressors 6

Breastfeeding-Specific Considerations

• Sertraline is the preferred antidepressant due to minimal passage into breastmilk and decades of safety data from the American Academy of Pediatrics 2
• The risks of untreated depression (poor bonding, infant neglect, impaired maternal self-care) outweigh theoretical medication risks 7, 8
• Untreated postpartum depression adversely affects infant cognitive, behavioral, and emotional development with effects potentially lasting into adolescence 1, 3

Psychosocial Support Interventions

• Actively maintain and leverage existing family support systems, as partner and family support are consistently protective factors 2
• Address relationship quality and chronic strains, which are among the strongest predictors of depression progression 1, 2
• Consider interpersonal therapy for navigating role transitions and resolving conflicts with close others 2

Outcome Priorities

Early identification and treatment are critical because: 1, 3

• Suicide is the second most common cause of maternal mortality in the US 1
• Untreated depression affects maternal quality of life, infant development, and family functioning 3
• Depression prevalence is approximately 15% during the first postpartum year, affecting approximately 1 in 7 mothers 1
• Postpartum depression is a leading cause of maternal morbidity and mortality 1