In a pregnant woman with a prior depressive episode, what is the risk of postpartum depression and how should her antidepressant therapy be managed during the peripartum period and while breastfeeding?

Risk of Postpartum Depression in Women with Prior Depression

Women with a history of depression face the highest risk of developing postpartum depression, with over 50% developing PPD after experiencing antenatal depression, making prior depression the single strongest predictor of peripartum mood disorders. 1, 2, 3

Quantifying the Risk

Prior depression history represents a moderate-to-strong risk factor consistently demonstrated across studies:

• Women who screened positive for antenatal depression developed PPD in 57.6% of cases in a 2023 cohort study of 578 women 3
• History of depression or anxiety is identified as one of the strongest predictors by the American Psychological Association 1
• The baseline PPD prevalence in the general population is 10-15%, with peak rates of 17.4% at 12 weeks postpartum 4, 5

This means women with prior depression have approximately 3-5 times higher risk than the general population.

Management of Antidepressant Therapy During Pregnancy

Continue vs. Discontinue Decision

Do not discontinue antidepressants during pregnancy in women with prior depression history, as discontinuation leads to significant relapse risk. 6

• A prospective study of 201 pregnant women with major depression history showed significantly increased relapse rates in those who discontinued antidepressants during pregnancy compared to those who continued treatment 6
• The risks of untreated maternal depression generally outweigh minimal risks of antidepressant exposure through breastmilk, according to the American College of Obstetricians and Gynecologists 7

Medication Selection During Pregnancy

Sertraline is the preferred antidepressant during pregnancy and postpartum:

• The American Academy of Family Physicians recommends sertraline as the preferred antidepressant when pharmacotherapy is needed 7
• Sertraline transfers to breast milk in lower concentrations than other antidepressants 7
• Most antidepressants are compatible with breastfeeding according to the American Academy of Pediatrics 4

Critical caveat: Paroxetine should be avoided due to association with cardiac malformations 2

Neonatal Monitoring Requirements

Neonates exposed to SSRIs in late third trimester require monitoring for:

• Respiratory distress, apnea, cyanosis 6
• Temperature instability, feeding difficulty 6
• Hypertonia, hyperreflexia, tremor, jitteriness, irritability 6
• Persistent pulmonary hypertension of the newborn (PPHN), though epidemiologic evidence is mixed 6

These complications can arise immediately upon delivery and may require prolonged hospitalization 6

Postpartum Management Strategy

Screening Timeline

Screen at multiple time points, not just early postpartum:

• Use Edinburgh Postnatal Depression Scale (EPDS) at each trimester and postpartum with 95% sensitivity and 93% specificity (cutoff ≥10) 4, 1
• Depression prevalence increases substantially over the first 12 weeks and throughout the first year, with higher rates at 7-12 months than earlier 4
• Peak prevalence occurs at 8-12 weeks postpartum (17.4%) 4

Treatment Initiation Threshold

For women with prior depression and new mild symptoms:

• Monitor closely for 2 weeks before initiating pharmacotherapy if symptoms are mild and of recent onset (≤2 weeks) 7
• Encourage exercise and social support during monitoring period 7

Initiate treatment immediately if:

• Symptoms persist beyond 2 weeks from initial diagnosis 7
• Symptoms worsen during monitoring period 7
• Depression is moderate-to-severe at presentation 7

Treatment Selection Algorithm

For mild depression (persisting >2 weeks):

• First-line: Cognitive behavioral therapy (CBT) or interpersonal psychotherapy (IPT) 7, 4

For moderate-to-severe depression:

• Combine CBT with sertraline for optimal outcomes 7, 4
• This combination decreases clinical morbidity more effectively than either treatment alone 7

Alternative delivery: Telemental health may be superior to in-person treatment, with mean difference of -2.99 (95% CI -4.52 to -1.46) on depression scales 7

Breastfeeding Considerations

Continue antidepressants while breastfeeding:

• Sertraline and paroxetine transfer to breast milk in lower concentrations, making them preferred options 7
• The American College of Obstetricians and Gynecologists states that risks of untreated maternal depression generally outweigh minimal risks of antidepressant exposure through breastmilk 7
• Most antidepressants are compatible with breastfeeding per the American Academy of Pediatrics 4

Additional Risk Factors to Monitor

In women with prior depression, assess these compounding risk factors:

• Antenatal EPDS score (higher scores predict PPD) 3
• Sleep quality postpartum (poor sleep strongly predicts PPD with standardized β = 0.226) 3
• Partner support and relationship quality 1
• Pyrexia during pregnancy (increases risk with standardized total β = 0.132) 3
• Obstetric complications: preterm delivery, cesarean delivery, preeclampsia 8
• Age extremes: <20 years or ≥35 years 8

Critical Pitfalls to Avoid

Do not delay treatment beyond 2 weeks if symptoms persist or worsen - untreated depression has significant negative consequences for maternal wellbeing and infant cognitive, behavioral, and emotional development 7, 1

Do not screen only in early postpartum - depression prevalence actually increases over time, requiring extended surveillance throughout the first year 4

Do not overlook comorbid anxiety disorders - anxiety affects approximately 16% of postpartum women and frequently co-occurs with PPD, negatively impacting treatment outcomes if unaddressed 7, 1

Do not confuse postpartum blues with PPD - blues is self-limited, resolving within 10-14 days, while depression requires minimum 2 weeks of symptoms with functional impairment 1