Medication can be an important treatment for antepartum and postpartum depression (PPD), if the symptoms are moderate-severe and/or not responding to non-medication approaches. The selective serotonin reuptake inhibitors (SSRIs) are the first line agents, in particular sertraline because of its relatively short half-life and availability of low doses (can be dosed as low as 12.5 mg per day). Paroxetine is pregnancy category D because of there is evidence that it increases the risk of birth defects, including rare cardiac and CNS effects. While these birth defects are very serious, it is important to keep in mind that they are very rare at baseline and that the increase in absolute risk from SSRI use is very minimal and depends on the SSRI being considered. There is also a possible connection between SSRI use in the third trimester of pregnancy and development of persistent pulmonary hypertension of the newborn in infants. There have been reports of newborns experiencing temporary discontinuation symptoms at birth, including jitteriness and irritability when a woman is treated with antidepressants during pregnancy. Other antidepressants, like the SNRIs and tricyclic antidepressants, are not typically recommended during pregnancy.

The SSRIs are also the first line medication treatment in the postpartum period for patients for whom medication might be indicated. Of the SSRIs, sertraline and paroxetine are the least detectable in breast milk, because of their relatively short half-lives. Several case reports note an association between fluoxetine and citalopram use in lactating women and infant irritability, poor sleep, poor feeding, crying, and restlessness. This might be related to these medications’ relatively longer half-life. Other case reports have not noted any adverse effects in infants of mothers taking fluoxetine and citalopram.  If one is considering treating PPD with a medication, sertraline is a good first line agent because of its relatively shorter half-life and ability to dose in smaller doses, as low as 12.5 mg per day. The peak level of sertraline in breast milk is between 7-10 hours after taking the medication, which can be kept in mind to determine the optimal time for the patient to take the medication. If a woman is already on an antidepressant like fluoxetine with a good response, it is okay to continue with the medication and monitor closely for side effects in the mother and infant.

The important take home point for treating depression related to pregnancy is to first consider a non-medication treatment. If it is determined medication is needed, it is important to have a careful discussion about the risks and benefits and to try to use the smallest possible dose for the shortest length of time, with sertraline being a good first choice for both the antepartum and postpartum period. 

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Postpartum Blues: Symptoms of mood lability, irritable mood, interpersonal hypersensitivity and tearfulness are common in the postpartum period and are commonly known as the postpartum “blues”. The incidence is up to 75% and the symptoms typically arise and resolve within 7-14 days after the delivery.

The following conditions are of more concern: depression during pregnancy (known as antepartum depression), postpartum depression (PPD) and postpartum psychosis.

Antepartum depression: The prevalence of depression during pregnancy ranges from 10-15% and it may persist into the first postpartum year. Depression during pregnancy is linked to birth complications like pre-eclampsia, low birth weight, premature delivery, and small for gestational age infants.

Postpartum depression: The prevalence of PPD is 10-15%. The postpartum year is one of the highest risk periods for first-onset depression for women with approximately 50% of women experiencing their first episode of depression during that time. In addition 25% of women with a history of Major Depressive Disorder will experience PPD and 50% of women who have had PPD will have a recurrence. The Edinburgh Postnatal Depression Scale and Postpartum Depression Screening Scale are useful screening tools. In addition to depressive symptoms, women with PPD typically also present with prominent anxiety symptoms that involve distressing and intrusive thoughts about infant safety and feelings of guilt and inadequacy about mothering. Infants of depressed mothers have been found to be less responsive and more irritable than infants of non-depressed mothers. Infants of depressed mothers are also more likely to develop an insecure attachment because of (unintentional) maternal rejection of the baby. If one suspects PPD it is important to rule out medical conditions, like thyroid dysfunction and iron-deficiency anemia, as these are more common during pregnancy and in the postpartum period.

Postpartum psychosis: Postpartum psychosis is rare and occurs in 1-2 women per 1000. The onset is typically within 2 weeks of delivery. The psychotic symptoms typically accompany affective symptoms of depression and anxiety, rather than represent a psychotic first break. Postpartum psychosis is more common in women who have a history of bipolar disorder. In addition to auditory and visual hallucinations, patients may present with cognitive impairment, confusion, and olfactory and tactile hallucinations. Many mothers are distressed because they experience command hallucinations to harm their infants. If postpartum psychosis is suspected, it is important to seek immediate psychiatric attention and to consider psychiatric hospitalization for the mother for her safety and for the infant’s safety. Antipsychotic medications are helpful for treating postpartum psychosis but it is more appropriate for the treatment to take place in a psychiatric hospital.

Treatment considerations for depression related to pregnancy will be discussed in the next e-Weekly.

Attached are a JAMA article about the timing of symptoms and the  Edinburgh Postnatal Depression Scale (EPDS) screening tool.

http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1666651

https://pc2education.files.wordpress.com/2012/05/edinburghscale.pdf