Postpartum Depression: Help Patients Find the Right Treatment: Accessibility of Treatment, Patient Preference, Breast-Feeding Help Guide Decisions
Freeman, Marlene P., Joffe, Hadine, Cohen, Lee S., Current Psychiatry
Postpartum depression (PPD)--emergence of a major depressive episode after childbirth--has broad negative consequences for the mother, baby, and other family members. The time of onset after delivery for a depressive episode to be considered postpartum is debatable, but the DSM-IV-TR specifier states that onset within 4 weeks of childbirth is considered postpartum. PPD can impact many aspects of child development, including mother-infant attachment, cognitive development, and behavior. (1-3)
An estimated 10% of women who have given birth experience PPD. (4-5) The risk of PPD is particularly high among women who have had previous episodes of PPD or major depressive disorder (MDD). Other risk factors include stressful life events, depression and/or anxiety during pregnancy, family history of PPD, and obstetrical complications. (6-8) Anxiety disorders are common in postpartum women, and anxiety symptoms often are prominent in PPD. (9)
Despite the prevalence of PPD and its serious consequences, few studies have addressed antidepressant treatment. In this article we discuss screening and treating PPD and considerations for breast-feeding mothers. Visit this article at CurrentPsychiatry.com for results of an open-label trial of escitalopram for PPD we conducted in which patient recruitment was challenging.
Screening for PPD: A good start
Initiatives by state governments and health care providers have led to programs in which universal screening for PPD has been implemented. Screening provides a mechanism for early detection and intervention. The Edinburgh Postnatal Depression Scale (10) is a self-rated, 10-item scale developed for the postpartum setting, and its use increases identification of PPD at postpartum obstetrics visits. (11) Other screening tools such as the Patient Health Questionnaire-9 also are commonly used. Despite the success of screening programs in attempting the feasibility of screening, it is unclear if the identification of women who may be experiencing PPD increases their engagement in treatment. Studies have demonstrated that even when depressive symptoms suggesting a PPD episode are identified in the postpartum period, many women still do not receive treatment. (12), (13) Studies of PPD screening programs have not demonstrated that screening itself improves treatment engagement or improves outcomes. (12), (13)
Multiple factors--including accessibility of treatment options and patient preference for specific types of treatment--determine whether mothers with PPD obtain treatment. Patients diagnosed with depression by a primary care clinician may prefer psychotherapy to antidepressants, (14) and a postpartum mother's willingness to accept antidepressant treatment may be influenced by concerns about possible risks during breast-feeding. (15)
Psychotherapy: An effective option
Psychotherapy is an important first-line option for PPD, particularly because of considerations of medication exposure during breast-feeding and many women are reluctant to take antidepressants while breast-feeding. (16) Interpersonal psychotherapy and cognitive-behavioral therapy (CBT) have been most studied for PPD, and both appear effective for prevention and acute treatment of PPD. (17-20) Although psychotherapy alone may be sufficient for some women, for others, medication may be an important first-line treatment, depending on symptom severity access to psychotherapy, and personal preference.
Evidence for antidepressants
Table 1 (page 15) (20-27) describes clinical trials that assessed the efficacy of antidepressants for PPD. Two relatively small, double-blind, placebo-controlled trials have evaluated selective serotonin reuptake inhibitors for PPD. In a randomized, double-blind study of CBT plus fluoxetine or CBT plus placebo (N = 87), fluoxetine was significantly more effective than placebo. (20) In a randomized, controlled trial of paroxetine vs placebo for PPD (N = 70), both groups improved as measured by the 17-item Hamilton Rating Scale for Depression or Inventory of Depressive Symptomatology-Self-Report; those who received paroxetine did not improve significantly more than those who received placebo. …