Clinical Approach to Identifying Postpartum Depression
Postpartum depression is often missed by providers and mothers (Chaudron et al., 2004; Bagedahl-Strindlund & Monsen, 1998; Morris-Rush, Freda & Bernstein, 2003; Heneghan et al., 2000). The symptoms of depression—depressed mood, sleep disruption, weight loss, fatigue, difficulty concentrating, anxiety, loss of interest in usual activities— can be difficult for mothers and providers to distinguish from the normal experiences of new mothers. It is also important to differentiate mothers suffering from postpartum depression from those with postpartum blues as misdiagnosis of such mothers can lead to unnecessary treatment. To distinguish symptoms of depression from the "baby blues," the timing (>2 weeks in duration, all day nearly every day) and the severity (functional impairment) must be evaluated (American Psychiatric Association, 2000).
For many women, acknowledgement of feelings other than happiness following the birth of their infant can be devastating and embarrassing. If mothers have thoughts of harming themselves or their infant, they are often afraid to bring these issues to their obstetrician, family physician, pediatrician, midwife, child health nurse, or other healthcare professional for fear that they will be labeled "crazy" or that their children will be taken away. Therefore, many women will not bring up their concerns or even identify them as a problem unless providers ask specific questions or use a screening tool (see Table 1 below).
Table 1. Recommendations for Identifying Women with Postpartum Depression
- The preferred method for identifying women with postpartum depression is the systematic use of a validated screening tool such as the Edinburgh Postnatal Depression Scale (Cox, Holden & Sagovsky, 1987) or the Postpartum Depression Screening Scale (Beck & Gable, 2000; Beck & Gable, "Comparative analysis," 2001; Beck & Gable, "Further validation," 2001) at the obstetrical postpartum visit and at well childcare visits in the postpartum year.
- Ask mothers if they feel down or anxious. Many women with postpartum depression report anxiety as a primary symptom rather than depressed mood or anhedonia. Excessive worrying about the baby's or mother's health should be explored.
- Ask mothers if they are having trouble sleeping even when they are exhausted and their child is sleeping (Chaudron et al., 2001) or if they are sleeping all the time and are unable to get out of bed.
- Ask mothers if they are losing or gaining weight. Many women with postpartum depression report a poor appetite, but they eat because they need to keep their strength up or for nursing. Some mothers will gain weight.
- Ask mothers directly but in an open, nonthreatening manner about thoughts or fears of harming their children. For example, "Many new mothers experience anxiety about their new infants. They may have thoughts that are unusual or frighten them such as fears that they may harm their baby. Does this ever happen to you?" (Wisner et al., 1999) Mothers who experience intrusive thoughts do not wish to harm their children and avoid the topics of their fears (i.e., a mother is afraid her baby will drown therefore will not bathe the baby and has her partner bathe the infant). It is important to distinguish the woman with postpartum depression whose intrusive thoughts or fears of harming the infant are incongruent with the mother's wish to keep her infant safe from the woman with postpartum psychosis who is delusional and who may have thoughts of harming her infant to "save the infant from the devil or a life of torment." Delusional mothers are at great risk of harming their infants or themselves and must be immediately evaluated by a psychiatrist (Spinelli, 2001).
- Ask mothers if they have concerns or questions about adapting to a new baby.
- Consider the mother's interactions with the infant, including the responsiveness of mom and baby.
- Difficulty in breastfeeding, or not enjoying breastfeeding, may be a warning sign that should be further evaluated.
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Clinical Approach to Treating Postpartum Depression
Once a woman is identified as suffering from postpartum depression, the choice of treatment must be considered. While no treatment is an option, it is not the preferred approach. Postpartum depression may last for months to years and can have long-term effects for the health and well-being of mothers and infants (Murray et al., 1996; Murray et al., 1999; Murray et al., 2003; Sinclair & Murray, 1998). In breastfeeding women with mild to moderate depression, the first-line treatment, if available, is psychotherapy. Psychotherapy can be an effective treatment for women with postpartum depression and carries no risks for the infants. Psychotherapy may also have the benefit of providing lasting changes in coping skills and adaptation to the new role of motherhood.
If psychotherapy is unavailable or unacceptable to the mother, or the symptoms are severe, antidepressants are an effective option. The approach to choosing an antidepressant is based on a variety of factors. No antidepressant is proven safer or more effective than another in the postpartum period or during lactation. The majority of drugs including all antidepressants are excreted in breastmilk. Data to inform clinical decisions are derived primarily from case reports or case series. Therefore, the initial treatment choice should be based on an informed clinical approach that takes into account the patient's previous treatments for depression, the targeted symptoms, family history of depression and their experiences with antidepressants, current and past medical disorders, current medications, allergies, side effects of the medications, and maternal wishes. An individualized risk-benefit analysis of the treatments must be conducted (see Table 2 in the original guideline document) (Burt et al., 2001).
Clinical Factors Affecting Antidepressant Choice
- There is no algorithm for antidepressant treatment choices in postpartum or lactating women; however, articles by experts in the field provide clinical guidance (Burt et al., 2001; Hendrick, Burt & Altshuler, 1996).
- Obtain a history of previous antidepressant treatment. In general, if a treatment was effective in the past and was tolerated, and there are no current contraindications, it is the likely first choice of treatment.
- Obtain a family history of treatment of depression. An immediate family member's history may be indicative of the mother's treatment response.
- Consider the primary symptoms that the medication will be targeting and the potential side effect profile of the antidepressant. For example, if the mother is particularly anxious, a medication that might heighten anxiety would not be the first choice. If the mother is experiencing hypersomnia, a medication with sedation as a side effect would not be the first choice. If a mother has somatic complaints such as nausea or diarrhea, a medication that may induce diarrhea would not be the first-line treatment.
Choosing an Antidepressant during Breastfeeding
When considering the use of any medication in a lactating woman, providers must consider the factors that influence infant serum levels, the most accurate measure of infant exposure. Factors affecting the passage of medication into breastmilk must be considered (route of administration, absorption rate, half-life and peak serum time, dissociation constant, volume of distribution, molecular size, degree of ionization, pH of plasma [7.4] and milk [6.8], solubility of the drug in water and in lipids, greater binding to plasma protein than to milk protein), factors affecting the amount of drug received by the infant (milk yield, colostrum vs. mature milk, concentration of the drug in the milk, how well the breast was emptied during the previous feeding), and an infant's ability to absorb, detoxify, and excrete the drug. Up-to-date information about medication use during lactation is available on TOXNET lactmed at http://toxnet.nlm.nih.gov. For information on specific antidepressants (i.e., selective serotonin reuptake inhibitors (SSRIs), selective serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs)/heterocyclics) and herbal alternatives used to treat postpartum depression in women, see the original guideline document.
Recommendations for Antidepressant Treatment in Lactating Women
- Current evidence suggests that the risks of untreated maternal depression can have serious and long-term effects on mothers and infants and that treatment may improve outcomes for mothers and infants. Therefore, treatment is strongly preferred.
- However, it is important not to label mothers who are only suffering from mild cases of "baby blues" as "depressed." We must make a distinction. If symptoms are mild, there is no reason to initiate antidepressant medication treatment in the first 2 weeks postpartum.
- When available and when symptoms are in the mild–moderate range, psychotherapy is the first line of treatment for lactating women as it carries no known risk for the infant. Mothers must be monitored and reevaluated. If they are not improving or their symptoms are worsening, antidepressant drug treatment must be considered.
- Psychotherapy in addition to antidepressant medication is recommended for women with severe symptoms.
- Women with moderate to severe symptoms may request only antidepressant drug treatment, and this must be considered as the benefits of treatment likely outweigh the risks of the medication to the mother or infant.
- There is no widely accepted algorithm for antidepressant medication treatment of depression in lactating women. An individualized risk-benefit analysis must be conducted in each situation and take into account the mother's clinical history and response to treatment, the risks of untreated depression, the risks and benefits of breastfeeding, the benefits of treatment, the known and unknown risks of the medication to the infant, and the mother's wishes.
- If a mother has no history of antidepressant treatments, an antidepressant, such as paroxetine or sertraline, that has evidence of lower levels in breastmilk and infant serum and few side effects is an appropriate first choice.
- If mothers have been successfully treated with a particular SSRI, TCA, or SNRI in the past, the data regarding this particular antidepressant should be reviewed, and it should be considered as a first-line treatment if there are no contraindications.
- Mothers should be provided the information regarding the known and unknown risks and benefits of the treatment to make an informed decision.
- Mothers should be monitored carefully in the initial stages of treatment for changes in symptoms, including worsening of symptoms. Specifically, women with histories of bipolar disorder, which may be undiagnosed, are at increased risk of developing a mood episode of depression, mania, or psychosis in the postpartum period. While this is rare, mothers and partners should be made aware of the symptoms to watch for such as increased insomnia, delusions, hallucinations, racing thoughts, and talking/moving fast and contact their mental health provider immediately.
- Infants should be evaluated prior to the initiation of a new medication during breastfeeding and monitored carefully by the pediatrician, including carefully following growth. Serum levels are not indicated on a regular basis without a clinical indication or concern.
- Strategies that may be used to decrease infant exposure, but for which there is little evidence, include medication administration immediately after feedings and pumping and discarding the breastmilk obtained during the peak serum levels.
