Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

depression

1st line – facilitated self-help strategies ± counselling ± a high intensity psychological intervention

Back
ACUTE
|
depression
|
persistent sub-threshold symptoms or mild symptoms
1st line – 

facilitated self-help strategies ± counselling ± a high intensity psychological intervention

Non-pharmacological treatment is typically recommended first-line.​[5][82]​​[150][151]​​ The local availability of psychological therapies is an important factor when determining which treatment to offer, as waiting times can be lengthy.

Facilitated self-help strategies include guided self-help, computerised cognitive behavioural therapy (CBT), and exercise.[88][152][153][154]​ This can be combined with non-directive counselling delivered at home (listening visits) and/or interpersonal psychotherapy (IPT).

Peer support and non-directive counselling, CBT, psychodynamic psychotherapy, and IPT are all effective in postnatal depression.[84]

Meta-analysis evidence suggests that the effects of psychological therapies remain significant at 6 to 12 months follow-up.[163]​ Psychological treatments probably also have effects on social support, anxiety, functional impairment, parental and marital stress.[163]​ 

Support for structured exercise may also be offered as a treatment option.[88][153][154]​​ 

Women requiring psychological treatment should be seen for treatment quickly, ideally within 1 month of initial assessment; in practice, management may be complicated by difficulties in accessing appropriate services at a regional and national level.[5]

Severity of depressive symptoms exists along a spectrum. In practice, the different categories of depression may not be completely clear cut; for example, there may be an overlap between mild-moderate and moderate-severe depression. Therefore, the non-pharmacological therapies listed above may also be suitable as a first-line option for some women with moderate depression who have symptoms at the milder end of the spectrum (sometimes referred to as mild-to-moderate depression).[5]

When a woman is experiencing a mental health disorder and has difficulties interacting with her infant, offer additional interventions specifically directed at this relationship. Consider the well-being of the infant at all times.

Consider – antidepressants

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ACUTE
|
depression
|
persistent sub-threshold symptoms or mild symptoms
Consider – 

antidepressants

Additional treatment recommended for SOME patients in selected patient group

Specific evidence for the pharmacological management of postnatal depression is limited.[167]​ Close mood monitoring is required in case a hypomanic or manic episode is triggered (e.g., due to undiagnosed bipolar disorder).

There are concerns among some clinicians that there is weaker evidence for efficacy of antidepressants in milder depression compared with more severe depression, although results are mixed there is an absence of clinical consensus; note that guidelines on management of mild postnatal depression differ internationally.[5][155][156][150]

UK guidance recommends against the use of antidepressants to treat sub-threshold and mild depressive symptoms, although antidepressants may be recommended if the woman has a past history of severe unipolar depression or if her symptoms persist after other interventions.[5]​ US guidance from the American College of Obstetricians and Gynecologists (ACOG) recommends non-pharmacological treatment first-line for mild-to-moderate depression occurring in the perinatal period.[82] ​However, ACOG emphasises that, in practice, psychological treatments are not always accessible or acceptable to individuals and that shared decision making is key, taking into account individual patient factors.[82]​ 

If pharmacological treatment is required, selective serotonin-reuptake inhibitors (SSRIs) are generally considered first-line medications for the treatment of depression, as they are in the general population with depression.[82]​ Choice of antidepressant will be determined by previous history of response and depend on whether or not the woman is breastfeeding.[82]​ US guidance from ACOG recommends that if a woman has been treated effectively with an antidepressant from a particular class in the past (e.g., with a particular SSRI or serotonin-noradrenaline reuptake inhibitor [SNRI]), then this medication should typically be the pharmacotherapy of choice for a new episode of depression occurring in the postnatal period.[82]​ 

For non-breastfeeding women, the choice of antidepressant is no different to that for episodes of major depression not occurring in the postnatal period and should be determined by the history of response to individual antidepressants. See Depression in adults.

For women who are breastfeeding, consider the evidence of safety in lactation, but also the possible negative implications of switching medication from an effective drug to one with uncertain efficacy and with marginal evidence of safety in breastfeeding.

If the mother uses antidepressants, observation of the neonate is recommended and breastfeeding encouraged.[150]

Certain antidepressants are considered safer than others in breastfeeding women but there is little data on the long-term outcomes for babies exposed to maternal antidepressant treatments through breast milk. One international review of clinical practice guidelines found that guidelines agree on antidepressants for severe depression with a preference for sertraline. ACOG echoes this, noting that sertraline is often preferred during breastfeeding due to its extensive and reassuring safety evaluation in the medical literature.[82]​ 

One meta-analysis examined the risk benefit analysis of sertraline during breastfeeding and found no significant relationship between maternal and infant sertraline levels.[170] According to a safety scoring system for psychotropic medications during lactation, sertraline and paroxetine had the highest scores representing a ‘very good safety profile’, and citalopram was assigned a ‘good safety profile’.[171] 

For women who are breastfeeding who do not respond to first-line treatment with SSRIs, specialist advice is typically required, but it is worth noting that, in general, SNRIs and mirtazapine appear to have limited passage into breast milk.[72]

New data are emerging and up-to-date advice from specialist services may be useful in individual cases.

Adverse effects may be greater in premature, very young, systemically unwell babies, and those with liver or kidney impairment; discussion with a paediatrician is recommended before prescribing a psychotropic drug to a breastfeeding mother in these circumstances.[172]

As with all drugs taken during breastfeeding, monitor the infant regularly for sedation, irritability, and any alteration in sleep, feeding, or growth pattern.​[91]​​​ There is little evidence to support disposing of breast milk or timing breastfeeding in relation to the timing of maternal drug administration; this type of recommendation may add to the difficulties of initiating breastfeeding.[91] There is limited evidence regarding the safety and efficacy of St John’s wort in women who are breastfeeding; therefore, it is advisable to recommend that women consider an alternative medication with greater evidence in breastfeeding.[173]​ 

Evidence on the safety of specific drugs for breastfeeding is a rapidly emerging area, and specialist advice may be required before prescribing.[5]

Further information about the potential toxic effects of pharmacological therapies is available online:

UK Teratology Information Service Opens in new window

Organization of Teratology Information Specialists: MotherToBaby Opens in new window

US National Library of Medicine: toxicology data network - drugs and lactation database Opens in new window

Women who are breastfeeding may be reluctant to take antidepressants due to concerns about risk to the baby.[102] If a woman with depression decides to stop taking psychotropic medication during the postnatal period, monitor her mental status to assess for ongoing risk of relapse and increase the level of support offered to her. Explore her reasons for doing so, and consider alternative treatment options such as starting a psychological intervention, restarting medication if the depression is or has been severe and there has been a previous good response to treatment, or switching to another medication (e.g., one with a safer profile during breastfeeding).[5][172]

1st line – high-intensity psychological intervention (CBT or IPT)

Back
ACUTE
|
depression
|
moderate-to-severe
1st line – 

high-intensity psychological intervention (CBT or IPT)

Non-pharmacological treatment is one potential first-line option.[5][82]

UK guidance recommends offering referral for a high-intensity psychological intervention alone for women with moderate-to-severe depression, if the woman expresses a preference for non-pharmacological treatment. US guidance from the American College of Obstetricians and Gynecologists (ACOG) recommends that psychological treatment is considered a first-line treatment recommendation for mild-to-moderate depression. ACOG emphasises that, in practice, psychological treatments are not always accessible or acceptable to individuals and that shared decision making is key, taking into account individual patient factors.

Cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT) are both similarly effective in postnatal depression.[84][158][159][160]​ Meta-analysis evidence suggests that the effects of psychological therapies remain significant at 6 to 12 months follow-up.[163]​ Psychological treatments probably also have effects on social support, anxiety, functional impairment, parental and marital stress.[163]​ 

Women requiring psychological treatment should be seen for treatment quickly, ideally within 1 month of initial assessment; in practice, management may be complicated by difficulties in accessing appropriate services at a regional and national level.[5] 

Consider the local availability of psychological therapies. It is vital to treat women with severe illness promptly, which often necessitates the use of antidepressant drugs if the waiting time for psychological treatment is too long.[5]

Electroconvulsive therapy may be considered when there is severe suicidality, psychosis, or treatment resistance.[72]​ Breastfeeding can be resumed as soon as the woman has recovered from anaesthesia and neuromuscular blockade.[91]

When a woman is experiencing a mental health disorder and has difficulties interacting with her infant, offer additional interventions specifically directed at this relationship. Consider the well-being of the infant at all times.

1st line – antidepressants

Back
ACUTE
|
depression
|
moderate-to-severe
1st line – 

antidepressants

Pharmacological treatment is one potential first-line option for moderate-to-severe postnatal depression.[5][82]

Antidepressants are recommended if the woman declines psychological therapy, if it is unavailable or does not work, if she has a preference for medication, or if she has a prior history of severe unipolar depression.[5]

Specific evidence for the pharmacological management of postnatal depression is limited.[167]

Close mood monitoring is required in case a hypomanic or manic episode is triggered (e.g., due to undiagnosed bipolar disorder).

If pharmacological treatment is required, selective serotonin-reuptake inhibitors (SSRIs) are generally considered first-line medications for the treatment of depression, as they are in the general population with depression.[82]​ Choice of antidepressant will be determined by previous history of response and depend on whether or not the woman is breastfeeding.[82]​ US guidance from the American College of Obstetricians and Gynecologists (ACOG) recommends that if a woman has been treated effectively with an antidepressant from a particular class in the past (e.g., with a particular SSRI or serotonin-noradrenaline reuptake inhibitor [SNRI]), then this medication should typically be the pharmacotherapy of choice for a new episode of depression occurring in the postnatal period.[82]​ 

For non-breastfeeding women, the choice of antidepressant is no different to that for episodes of major depression not occurring in the postnatal period and should be determined by the history of response to individual antidepressants. See Depression in adults.

For women who are breastfeeding, consider the evidence of safety in lactation, but also the possible negative implications of switching medication from an effective drug to one with uncertain efficacy and with marginal evidence of safety in breastfeeding.

If the mother uses antidepressants, observation of the neonate is recommended and breastfeeding encouraged.[150]

​Certain antidepressants are considered safer than others in breastfeeding women but there is little data on the long-term outcomes for babies exposed to maternal antidepressant treatments through breast milk. One international review of clinical practice guidelines found that guidelines agree on antidepressants for severe depression with a preference for sertraline. ACOG echoes this, noting that sertraline is often preferred during breastfeeding due to its extensive and reassuring safety evaluation in the medical literature.[82]​ 

One meta-analysis examined the risk benefit analysis of sertraline during breastfeeding and found no significant relationship between maternal and infant sertraline levels.[170] According to a safety scoring system for psychotropic medications during lactation, sertraline and paroxetine had the highest scores representing a ‘very good safety profile’, and citalopram was assigned a ‘good safety profile’.[171] 

For women who are breastfeeding who do not respond to first-line treatment with SSRIs, specialist advice is typically required, but it is worth noting that, in general, SNRIs and mirtazapine appear to have limited passage into breast milk.[72]

New data are emerging and up-to-date advice from specialist services may be useful in individual cases.

Adverse effects may be greater in premature, very young, systemically unwell babies, and those with liver or kidney impairment; discussion with a paediatrician is recommended before prescribing a psychotropic drug to a breastfeeding mother in these circumstances.[172] As with all drugs taken during breastfeeding, monitor the infant regularly for sedation, irritability, and any alteration in sleep, feeding, or growth pattern.​[91]​​ There is little evidence to support disposing of breast milk or timing breastfeeding in relation to the timing of maternal drug administration; this type of recommendation may add to the difficulties of initiating breastfeeding.[91] There is limited evidence regarding the safety and efficacy of St John’s wort in women who are breastfeeding; therefore, it is advisable to recommend that women consider an alternative medication with greater evidence in breastfeeding.[173]​ 

Evidence on the safety of specific drugs for breastfeeding is a rapidly emerging area, and specialist advice may be required before prescribing.[5] Further information about the potential toxic effects of pharmacological therapies is available online: 

UK Teratology Information Service Opens in new window

Organization of Teratology Information Specialists: MotherToBaby Opens in new window

US National Library of Medicine: toxicology data network - drugs and lactation database Opens in new window

Women who are breastfeeding may be reluctant to take antidepressants due to concerns about risk to the baby.[102] If a woman with depression decides to stop taking psychotropic medication during the postnatal period, monitor her mental status to assess for ongoing risk of relapse and increase the level of support offered to her. Explore her reasons for doing so, and consider alternative treatment options such as starting a psychological intervention, restarting medication if the depression is or has been severe and there has been a previous good response to treatment, or switching to another medication (e.g., one with a safer profile during breastfeeding).[5][172]

Electroconvulsive therapy may be considered when there is severe suicidality, psychosis, or treatment resistance.[72]​ Breastfeeding can be resumed as soon as the woman has recovered from anaesthesia and neuromuscular blockade.[91]

2nd line – antidepressants + a high-intensity psychological intervention (CBT or IPT)

Back
ACUTE
|
depression
|
moderate-to-severe
2nd line – 

antidepressants + a high-intensity psychological intervention (CBT or IPT)

Combination treatment with antidepressants and cognitive behavioural therapy (CBT) or interpersonal psychotherapy (IPT) should be offered if there is no, or a limited, response to psychological or drug treatment alone.[5]

Close mood monitoring is required in case a hypomanic or manic episode is triggered (e.g., due to undiagnosed bipolar disorder).

If pharmacological treatment is required, selective serotonin-reuptake inhibitors (SSRIs) are generally considered first-line medications for the treatment of depression, as they are in the general population with depression.[82]​ Choice of antidepressant will be determined by previous history of response and depend on whether or not the woman is breastfeeding.[82]​ US guidance from ACOG recommends that if a woman has been treated effectively with an antidepressant from a particular class in the past (e.g., with a particular SSRI or serotonin-noradrenaline reuptake inhibitor [SNRI]), then this medication should typically be the pharmacotherapy of choice for a new episode of depression occurring in the postnatal period and should be determined by the history of response to individual antidepressants.[82]​ 

For non-breastfeeding women, the choice of antidepressant is no different to that for episodes of major depression not occurring in the postnatal period and should be determined by the history of response to individual antidepressants. See Depression in adults.

For women who are breastfeeding, consider the evidence of safety in lactation, but also the possible negative implications of switching medication from an effective drug to one with uncertain efficacy and with marginal evidence of safety in breastfeeding.

If the mother uses antidepressants, observation of the neonate is recommended and breastfeeding encouraged.[150]

Certain antidepressants are considered safer than others in breastfeeding women but there is little data on the long-term outcomes for babies exposed to maternal antidepressant treatments through breast milk. One international review of clinical practice guidelines found that guidelines agree on antidepressants for severe depression with a preference for sertraline. ACOG echoes this, noting that sertraline is often preferred during breastfeeding due to its extensive and reassuring safety evaluation in the medical literature.[82]​ 

One meta-analysis examined the risk benefit analysis of sertraline during breastfeeding and found no significant relationship between maternal and infant sertraline levels.[170] According to a safety scoring system for psychotropic medications during lactation, sertraline and paroxetine had the highest scores representing a ‘very good safety profile’, and citalopram was assigned a ‘good safety profile’.[171] Choice of antidepressant will be determined by previous history of response and depend on whether or not the woman is breastfeeding.

For women who are breastfeeding who do not respond to first-line treatment with SSRIs, specialist advice is typically required, but it is worth noting that, in general, SNRIs and mirtazapine appear to have limited passage into breast milk.[72]

New data are emerging and up-to-date advice from specialist services may be useful in individual cases.

Adverse effects may be greater in premature, very young, systemically unwell babies, and those with liver or kidney impairment; discussion with a paediatrician is recommended before prescribing a psychotropic drug to a breastfeeding mother in these circumstances.[172] As with all drugs taken during breastfeeding, monitor the infant regularly for sedation, irritability, and any alteration in sleep, feeding, or growth pattern.​[91]​​ There is little evidence to support disposing of breast milk or timing breastfeeding in relation to the timing of maternal drug administration; this type of recommendation may add to the difficulties of initiating breastfeeding.[91] There is limited evidence regarding the safety and efficacy of St John’s wort in women who are breastfeeding; therefore, it is advisable to recommend that women consider an alternative medication with greater evidence in breastfeeding.[173]​​ 

Evidence on the safety of specific drugs for breastfeeding is a rapidly emerging area, and specialist advice may be required before prescribing.[5] Further information about the potential toxic effects of pharmacological therapies is available online: 

UK Teratology Information Service Opens in new window

Organization of Teratology Information Specialists: MotherToBaby Opens in new window

US National Library of Medicine: toxicology data network - drugs and lactation database Opens in new window

Women who are breastfeeding may be reluctant to take antidepressants due to concerns about risk to the baby.[102] If a woman with depression decides to stop taking psychotropic medication during the postnatal period, monitor her mental status to assess for ongoing risk of relapse and increase the level of support offered to her. Explore her reasons for doing so, and consider alternative treatment options such as starting a psychological intervention, restarting medication if the depression is or has been severe and there has been a previous good response to treatment, or switching to another medication (e.g., one with a safer profile during breastfeeding).[5][172]

Electroconvulsive therapy may be considered when there is severe suicidality, psychosis, or treatment resistance.[72]​ Breastfeeding can be resumed as soon as the woman has recovered from anaesthesia and neuromuscular blockade.[91]

When a woman is experiencing a mental health disorder and has difficulties interacting with her infant, offer additional interventions specifically directed at this relationship. Consider the well-being of the infant at all times.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer