Winter 2006
 

The Identification and Treatment of Postpartum Depression
Joy Moel, MA, Department of Counseling Psychology
Scott Stuart, MD, Department of Psychiatry, University of Iowa
Iowa Depression and Clinical Research Center

Experts agree that about one mother in ten experiences postpartum depression. Despite the high incidence of postpartum depression, however, it remains largely unrecognized -- both by affected women and by their health care providers. In one study, 97% of women with postpartum depression reported that they felt there was "something wrong," but only 32% believed they were suffering from depression. Many felt their symptoms were either not severe enough to merit treatment or attributed them to family or child care difficulties. Most strikingly, only 10% discussed their symptoms with a health care professional. Current research indicates that standardized screening of all postpartum women is essential in order to increase identification and treatment of postpartum depression.

Identifying postpartum depression

Primary care providers, particularly family practitioners, obstetricians, and pediatricians, play a key role in recognizing postpartum illness. As many new mothers will have little contact with their obstetricians after the first six weeks postpartum, it is often physicians caring for newborns who have the most contact with these women. All postpartum women should be screened for depression; instruments such as the Edinburgh Postnatal Depression Scale are easy to use and have been validated for this purpose. A recent study reported an increase in detection rates from 3.7% to 10.7% after one year of universal screening.
 

Treating postpartum depression

Medication. Any of the commonly used antidepressant medications for postpartum depression may be prescribed for new mothers with postpartum depression who are not breastfeeding. If there is a history of depression, the choice of medication should be based on the woman’s previous response to medication or her family’s  history of response to treatment. When considering the treatment of depression in women who breastfeed, it is important to be aware of the risks posed by untreated depression, especially the adverse effects it can have on child development.

The risks of medication and the benefits of treatment should be carefully weighed. Experts agree that moderate to severe depression in nursing mothers should be treated with

 medication. Current data suggest that the use of tricyclic antidepressants and the selective serotonin re-uptake inhibitors (SSRIs) is relatively safe for the breastfeeding infant.

A recent analysis of antidepressant levels in  lactating mothers suggests that nortriptyline, paroxetine, and sertraline may be the preferred  choices for breast-feeding women. The general opinion of experts in the field is that fluoxetine should be avoided while breastfeeding due to its long half- life, unless a woman has responded well to treatment with fluoxetine previously.

Though fewer women have been treated postpartum with the new generation antidepressants, these medications also appear to be relatively safe during breastfeeding. Electroconvulsive therapy can be safely used for women with psychotic depression, and for those who do not respond to other treatments.

In sum, the current clinical consensus is that antidepressants can and should be used with breastfeeding women who have moderate to severe depression. Because commonly used antidepressant medications appear safe, the guidelines for selection of medication described above (such as previous response or family history of response to treatment) should be used. Supplementation of breastfeeding with bottle feeding during times of peak exposure may also reduce risks to infants.

Psychotherapy. Despite data supporting the relative safety of antidepressant medications during breastfeeding, many women are wary of their use. In one study, only 20% of women with postpartum depression said that they would consider using antidepressant medications. Psychotherapy is an effective and empirically validated alternative for women who do not want to use medications while breastfeeding. The use of interpersonal psychotherapy over 12 to 16 weeks has been shown by University of Iowa investigators to be of great benefit for depression; cognitive, group, family, and mother-infant therapy may also be helpful.