Postpartum Depression: Help Patients Find the Right Treatment: Accessibility of Treatment, Patient Preference, Breast-Feeding Help Guide Decisions

By Freeman, Marlene P.; Joffe, Hadine et al. | Current Psychiatry, November 2012 | Go to article overview
Save to active project

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)

[ILLUSTRATION OMITTED]

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.

The rest of this article is only available to active members of Questia

Sign up now for a free, 1-day trial and receive full access to:

  • Questia's entire collection
  • Automatic bibliography creation
  • More helpful research tools like notes, citations, and highlights
  • Ad-free environment

Already a member? Log in now.

Notes for this article

Add a new note
If you are trying to select text to create highlights or citations, remember that you must now click or tap on the first word, and then click or tap on the last word.
Loading One moment ...
Project items
Notes
Cite this article

Cited article

Style
Citations are available only to our active members.
Sign up now to cite pages or passages in MLA, APA and Chicago citation styles.

Cited article

Postpartum Depression: Help Patients Find the Right Treatment: Accessibility of Treatment, Patient Preference, Breast-Feeding Help Guide Decisions
Settings

Settings

Typeface
Text size Smaller Larger
Search within

Search within this article

Look up

Look up a word

  • Dictionary
  • Thesaurus
Please submit a word or phrase above.
Print this page

Print this page

Why can't I print more than one page at a time?

While we understand printed pages are helpful to our users, this limitation is necessary to help protect our publishers' copyrighted material and prevent its unlawful distribution. We are sorry for any inconvenience.
Full screen

matching results for page

Cited passage

Style
Citations are available only to our active members.
Sign up now to cite pages or passages in MLA, APA and Chicago citation styles.

Cited passage

Welcome to the new Questia Reader

The Questia Reader has been updated to provide you with an even better online reading experience.  It is now 100% Responsive, which means you can read our books and articles on any sized device you wish.  All of your favorite tools like notes, highlights, and citations are still here, but the way you select text has been updated to be easier to use, especially on touchscreen devices.  Here's how:

1. Click or tap the first word you want to select.
2. Click or tap the last word you want to select.

OK, got it!

Thanks for trying Questia!

Please continue trying out our research tools, but please note, full functionality is available only to our active members.

Your work will be lost once you leave this Web page.

For full access in an ad-free environment, sign up now for a FREE, 1-day trial.

Already a member? Log in now.

Are you sure you want to delete this highlight?