Approach

Guidelines recommend a stepwise approach to the treatment of postpartum depression, although it is important that women with severe illness receive appropriate treatment quickly rather than working through various levels of treatment. Treatment can be effectively organized via primary care.[5] In some locations such as the UK, initial treatment can be effectively organized via primary care, although a multidisciplinary approach may ultimately be required (e.g., for those with severe or complex depression).​​​ In the US, obstetricians typically play a key role in the initial assessment and pharmacologic management of perinatal mental illness, aided by Perinatal Psychiatry Access Programs where such services are available.[82] Massachusetts Department of Mental Health: ​MCPAP for Moms Opens in new window​​ Furthermore, evidence from two US studies suggests advantages to a collaborative care approach for perinatal depression, a structured health services intervention that includes a care manager (typically a licensed clinical social worker) to coordinate patient-centered care delivery.[144][145]​​​

Timely treatment of perinatal mental health problems in the perinatal period is paramount. UK guidance recommends that women with a known, or suspected, mental health problem in pregnancy or the postpartum period should be assessed for treatment within 2 weeks of referral, and receive psychological interventions within 1 month of initial assessment;[5] in practice, management may be complicated by difficulties in accessing appropriate services at a regional and national level.

Urgent referral to specialist mental health services is required for patients with suicidal ideation, thoughts of harming the child, a very severe episode, and/or features that raise suspicion of bipolar illness or postpartum psychosis.[4][5] Specialist psychiatric input during pregnancy and in the postpartum period is recommended in the UK for women at high risk of developing depression because of a history of severe depression, even if they are currently well.[5] Clinicians are advised to ensure that the woman's family practitioner knows about the referral.[5]

Before treatment decisions are made, discuss with the patient the absolute and relative risks associated with treating and not treating the depression.

Postpartum depression presents with a heterogeneity of symptoms and phenotypes, and both nonpharmacologic and pharmacologic treatments should be considered, taking into account the severity of the condition. Additionally, availability of psychological treatment is a key practical consideration in some locations. The woman’s preferences are important, and care should be individualized to meet her particular needs.[146]

Depression is defined within international diagnostic systems as mild, moderate, and severe, according to the number of symptoms, intensity of symptoms, and level of functional impairment, as follows.[1]

  • Mild: few if any symptoms in excess of those required to make a diagnosis of depression, the intensity of which is distressing but manageable, with minor impairment of social or occupational functioning.

  • Moderate: the number of symptoms for diagnosis of depression, intensity of symptoms, and impairment in functioning are greater between those specified for "mild" or "severe" depression.

  • Severe: many more symptoms than required for diagnosis of depression, the intensity of which is seriously distressing and unmanageable, symptoms markedly interfere with social and occupational functioning.

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. In these cases, it may be helpful then to focus on the extent of the functional impairment and on the presence of any specific symptoms such as psychotic phenomena.[102]

Persistent subthreshold depressive symptoms or mild depression

For a woman who develops persistent subthreshold depressive symptoms or mild depression during the postpartum period, consider offering a nonpharmacologic treatment in the first instance, such as:​[5]​​[82][147][148]​​​​

  • Facilitated self-help strategies (e.g., guided self-help, computerized cognitive behavioral therapy, exercise)[88][149][150][151]​​

  • Nondirective counseling in the context of home visits

  • Brief cognitive behavioral therapy (CBT) or interpersonal psychotherapy (IPT).[Evidence C]

UK guidance from the UK National Institute of Health and Care Excellence does not recommend the use of antidepressants to treat subthreshold and mild depressive symptoms, except if there is 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), while not offering specific advice on direct delivery of psychotherapy, echoes the above general approach, recommending that psychological treatment is considered a first-line treatment recommendation for mild-to-moderate depression in the perinatal period. However, ACOG emphasizes 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]​

​In postpartum depression, as in depression occurring in the general adult population, there is uncertainty about the efficacy of treatments for less severe symptoms. In particular, concerns have been noted by some experts that there is weaker evidence for efficacy of antidepressants in milder depression compared with more severe depression, although results are mixed and there is an absence of clinical consensus.[5][152][153][147]​ Results from one meta-analysis of adults with depression in general (not just postpartum depression) suggest number needed to treat (NNT) values of 16, 11, and 4 for the mild-to-moderate, severe, and very-severe subgroups, respectively.[154]

The management recommended above may also be suitable 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]

Moderate or severe depression

For a woman who develops either a moderate or severe postpartum depressive episode, consider the following:[5][82]

  • Referral for a high-intensity psychological intervention (e.g., CBT/IPT);[155][156][Evidence C] for example, if the woman expresses a preference for nonpharmacologic treatment 

  • Antidepressant therapy if the woman expresses a preference for medication, declines psychological interventions, if her symptoms have not responded to psychological interventions, or if she has a history of severe depression[5]

  • Combination treatment if there is no, or a limited, response to psychological or drug treatment alone.[5]

The local availability of psychological therapies is an important factor when determining which treatment to offer, as waiting times can be lengthy. It is vital to treat women with severe illness promptly, which often necessitates the use of antidepressant drugs.[5] Previous responses to treatments can inform therapeutic choices.

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

Nonpharmacologic therapy for depression: general principles

Women requiring psychological treatment should be seen for treatment quickly, ideally within 1 month of initial assessment according to UK guidance, although in practice service availability varies according to location of practice.[5] In the US, access to psychological treatments remain limited for many postpartum women, including but not limited to those who are non-English-speaking, uninsured, or geographically isolated.[82]

One Cochrane meta-analysis of 10 trials of psychological and psychosocial interventions concluded that peer support and nondirective counseling, CBT, psychodynamic psychotherapy, and IPT are all effective in postpartum depression.[84] Efficacy of CBT and IPT appears similar overall.[84][155][156][157]​​​​ 

Peer support is unique among psychosocial interventions in that it is delivered by an individual with lived experience of the condition; there is some evidence that it reduces symptoms of postpartum depression.[158]​ Narrative evidence suggests that women find peer support highly acceptable.[159]

Meta-analysis evidence suggests that the effects of psychological therapies remain significant at 6 to 12 months follow-up.[160]​ Psychological treatments probably also have effects on social support, anxiety, functional impairment, parental and marital stress.[160]​ Support for structured exercise may also be offered as a treatment option.[88][150][151]​ If the mother-baby relationship is impaired, offer additional interventions specifically directed at this relationship. Consider the well-being of the infant at all times. 

Telemental health is an emerging field with remote service-delivery applications, such as phone, email or app-based interventions. It has been suggested that women of reproductive age may be good candidates for electronic health (eHealth) delivery methods, given that they are typically frequent users of the internet, social media, and smartphone apps.[143] However, at present there are limited randomized controlled trial (RCT) data on eHealth interventions specific to postpartum depression, and further evidence is required regarding the safety, efficacy, and acceptability of such approaches.[161][162]​​​ Online interventions that include elements of peer support are also under investigation.[163]​ Future research on eHealth applications may help improve access to evidence-based psychological treatments.  

Pharmacologic therapy for depression: general principles

Evidence for the pharmacologic management of postpartum depression, and for evaluating the comparative harms and benefits of specific antidepressants, is insufficient.[164]​ Antidepressants are often prescribed for postpartum depression, following the same principles as for other types of major depressive disorder. One Cochrane review found low-certainty evidence that selective serotonin-reuptake inhibitors (SSRIs) are more effective for postpartum depression than placebo.[164]

Screening for undiagnosed bipolar disorder prior to initiating treatment with an antidepressant is strongly recommended, due to the risk of iatrogenic precipitation of mania or psychosis with unopposed antidepressant treatment in undiagnosed bipolar disorder.[82] See Bipolar disorder in adults.​ If antidepressant therapy is given, patients require careful mood monitoring for manic or hypomanic symptoms.[82]

The choice of treatment depends on the woman's preference, previous responses to treatment, local availability of psychological therapies, the severity of the illness, the risks involved, and whether or not the woman is breast-feeding. For nonbreast-feeding women, the choice of antidepressant is no different to that for episodes of major depression not occurring in the postpartum period and should be determined by the history of response to individual antidepressants. See Depression in adults.

Pharmacologic therapy during lactation

If a woman has been stable on a particular medication for depression throughout pregnancy, the medication should typically be continued into the postpartum period regardless of breast-feeding status unless there is a particular reason to stop treatment. The rationale is that fetal exposure is greater than exposure during lactation.[82]

With respect to the decision about whether to start a new medication when a woman is breast-feeding, the risk-benefit balance of pharmacologic therapy is altered, and evidence on passage through the breast milk should be considered alongside other factors including likelihood of drug efficacy. Factors that might tip the balance in favor of antidepressant therapy during breast-feeding include where the woman has expressed a preference for medication, if she declines psychological interventions, if her symptoms have not responded to psychological interventions, or if she has a history of severe depression.[5]​ In general, ACOG recommends against withholding or discontinuing medications for mental health conditions due to pregnancy or lactation status alone.[82]

​Before discussing the risks and benefits of a potential pharmacologic therapy in women who are breast-feeding, specialist advice may be indicated.[5] In the US, this discussion may typically be carried out by the patient’s obstetrician.[82]​ Acknowledge the uncertainty of the degree of risk with specific psychotropic medications and consider the risks of exposure during breast-feeding to the child, including developmental or longer-term effects, but also the risks and impacts of untreated depression on both the mother and child.[91] ACOG recommends that clinicians consider untreated or inadequately treated mental health disorders in the perinatal period as an exposure given their associated risks.[82]

As with any treatment plan, the aim is to use the lowest dose that achieves the clinical goal.[82]​ If the mother uses antidepressants, observation of the neonate is recommended and breast-feeding encouraged.[147]​

First-line pharmacologic treatment, as with depression occurring in the general population, is typically with a SSRI. When SSRIs are ineffective, alternative medications may include serotonin-norepinephrine reuptake inhibitors (SNRIs) or mirtazapine, taking into consideration evidence of safety regarding passage through breast milk (see below).[72]

Treatment selection during lactation

SSRIs are generally considered first-line medications for the treatment of depression in general, including during breast-feeding.[82]

For women already established on a particular drug, consider the possible negative implications of switching medication from an effective drug to one with uncertain efficacy and with marginal evidence of safety in breast-feeding. 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 SNRI), then this medication should typically be the pharmacotherapy of choice for a new episode of depression occurring in the postpartum period.[82]

For nonbreast-feeding women, the choice of antidepressant is no different to that for episodes of major depression not occurring in the postpartum period.

Certain antidepressants are considered safer than others in breast-feeding women, but there is a lack of 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.[147]​ Two RCTs have evaluated the efficacy of sertraline for postpartum depression, with positive results compared with placebo, although sample sizes were small.[165][166]​​

ACOG notes that sertraline is often preferred during breast-feeding due to its extensive and reassuring safety evaluation in the medical literature.[82]​ One meta-analysis examined the risk benefit analysis of sertraline during breast-feeding and found no significant relationship between maternal and infant sertraline levels.[167] 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".[168]

​For women who are breast-feeding 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 ill babies, and those with liver or kidney impairment; discussion with a pediatrician is recommended before prescribing a psychotropic drug to a breast-feeding mother in these circumstances.[169] As with all drugs taken during breast-feeding, 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 breast-feeding in relation to the timing of maternal drug administration; this type of recommendation may add to the difficulties of initiating breast-feeding.[91] There is limited evidence regarding the safety and efficacy of St John’s wort in women who are breast-feeding; therefore, it is advisable to recommend that women consider an alternative medication with greater evidence in breast-feeding.[170]​ 

​Evidence on the safety of specific drugs for breast-feeding is a rapidly emerging area.[5] Further information about the potential toxic effects of pharmacologic therapies is available online: 

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

UK Teratology Information Service Opens in new window

Academy of Breastfeeding Medicine: Clinical Protocol #35: Supporting Breastfeeding During Maternal or Child Hospitalization Opens in new window

Women who are breast-feeding 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 postpartum 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 breast-feeding).[5][169]

Although, in general, breast-feeding is associated with improved maternal mental health outcomes, for some women difficulties with breast-feeding may precipitate or worsen postpartum depression.[171]​ Take an individualized approach, but it may be appropriate in some circumstances to recommend consideration of formula feeding as a healthy alternative to breast-feeding, taking into account the family’s ability to access clean water.[72]

Measuring treatment response

US guidance from ACOG recommends that clinicians use the same validated screening tool to monitor for response to treatment of depression symptoms. (See Screening.) If clinically indicated, drug doses may need to be up-titrated, with the goal being remission of symptoms of depression.[82]​ Under-treatment in the perinatal period is common, and results in exposures to both the underlying illness and pharmacologic agent.

Duration of treatment

Data to guide clinicians on optimal treatment duration for postpartum depression are currently limited. As a general guide, based on expert opinion, consider continuing pharmacologic treatment for postpartum depression for at least 6 to 12 months following symptom remission before considering discontinuation. In the event of future pregnancies, note that, in general, discontinuing effective pharmacotherapy during pregnancy or in the early postpartum period carries a higher risk of relapse.[82]

If discontinuation of antidepressant treatment is required, slowly decrease the dose to reduce the risk of unpleasant withdrawal symptoms; this may take as long as several months at a rate that is tolerable to the patient. Closely monitor the patient to ensure that any apparent emerging withdrawal symptoms do not in fact represent a relapse of their depression.[152]

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