postpartum%20depression
POSTPARTUM DEPRESSION

Postpartum depression is the occurrence of a major depressive episode within 4 weeks following delivery or up to a year after childbirth.

It may peak at 2-4 weeks and 10-14 weeks after childbirth.

Symptoms are similar to that of major depression but with additional features distinctive of the postpartum period like feelings of being overwhelmed and inadequate as a parent.

Postpartum%20depression Treatment

Non-Pharmacological Therapy

  • Treatment goals include diminishing depressive symptoms, preventing suicide and infanticide, and restoring patient’s functionality

Psychosocial Interventions

  • For patients with mild symptoms, psychosocial interventions are encouraged, eg peer and partner support, nondirective counseling
  • May be conducted in person or via a phone call
  • A meta-analysis of 5 trials demonstrated that women who were given psychosocial interventions were less likely to still be depressed 1 year after childbirth than those who were given standard postpartum care

Psychotherapy

  • For patients with moderate symptoms and those who are unresponsive to psychosocial interventions, a formal psychotherapy is considered
    • May be used together with medical therapy in the management of severe PPD
  • May include cognitive behavioral therapy, interpersonal therapy, psychodynamic or insight-oriented therapy, or group therapy (therapist and/or peer led)
  • May be used with individuals, groups or couples/families and are effective for prevention and treatment of PPD
  • Patients who underwent psychotherapy for 6 months have lower depression levels and higher remission rates compared to those who were given standard postpartum care

Electroconvulsive Therapy

  • May be considered in women with severe depression who did not respond to medical therapy, those with an acute episode of psychosis, or when patients have suicidal ideation
    • It is safe for the baby and breastfeeding may be continued
  • A valid consent must be obtained at all times if the patient can provide one; if not possible, advance directives or patient’s partner and/or family must be consulted

Other Interventions

  • Other non-pharmacological therapy interventions include the following though further studies are needed to demonstrate efficacy: Acupuncture, bright-light or phototherapy, repetitive transcranial magnetic stimulation

Pharmacotherapy

Principles of Therapy

  • Indications include PPD symptoms unresponsive to psychosocial interventions or psychotherapy, severe symptoms needing immediate treatment, high risk of relapse, or patient preference
  • No evidence has shown that any single antidepressant agent is more effective than another in treating PPD
  • Consider using the antidepressant agent that was previously effective for the patient
    • Though may also consider changing medication if there is a drug which is also effective for the patient but has lower risk of adverse effects
  • Begin antidepressant treatment with the lowest effective dose, titrating gradually to full therapeutic dose
  • Treatment duration of the acute phase is 2-3 months while for the maintenance phase, it is advised that treatment duration with antidepressants be 6-12 months after complete remission to decrease risk of relapse
    • A longer treatment duration may be needed in patients with recurrent depressive episodes
  • All medications are excreted into the breast milk, though concentration in breast milk varies between drugs
    • Carefully decide on whether to discontinue nursing due to the risks of drug effects on the infant or to discontinue the drug, taking into account the risk of untreated depression in the mother
    • If breastfeeding will be continued while on medications, the infant should be monitored for symptoms such as decreased feeding, poor weight gain, sleep problems, irritability

Brexanolone

  • A neuroactive steroid GABAA receptor positive modulator, it is the first US FDA-approved drug specific for PPD 
  •  It is an exogenously produced analog of allopregnanolone, a metabolite of progesterone  
    • Allopregnanolone concentration rises during pregnancy and declines after birth; this decline is thought to cause PPD and anxiety  
  • Brexanolone injection, in a matched-adjusted indirect comparison, was shown to rapidly relieve PPD compared to SSRIs based on the patient-reported EPDS and the clinician-reported Hamilton Depression Rating Scale (HAM-D)  
  • Due to serious risk of excessive sedation or sudden loss of consciousness during administration, it is only available to patients enrolled in the restricted distribution program at certified healthcare facilities where a healthcare provider can monitor the patient as part of the Risk Evaluation and Mitigation Strategy (REMS) 

Selective Serotonin Reuptake Inhibitors (SSRIs)

  • Eg Sertraline, Paroxetine, Fluoxetine, Citalopram
  • Recommended for medication-naïve patients
  • May be given to women breastfeeding healthy full-term infants as concentration of these agents in breast milk is low
    • Excreted dose into breast milk is considered low risk if infant dose is <10% compared with maternal level
  • Women effectively treated with above SSRI agents during pregnancy may continue therapy while breastfeeding if without contraindications; however, SSRI use during pregnancy may delay lactogenesis
  • Response to therapy may be noted after 2-3 weeks

Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)

  • Eg Venlafaxine
  • Used when SSRI treatment had been ineffective or when patient had a previous positive response to treatment with these agents
  • Current data also show these agents pass minimally into breast milk

Tricyclic Antidepressants (TCAs)

  • Eg Nortriptyline, Imipramine
  • Due to its anticholinergic adverse effects, treatment with TCAs is considered 2nd or 3rd line

Adjunctive Therapy

  • Benzodiazepines
    • May be useful in patients with anxiety, insomnia or both
    • Monitor infant for adverse drug effects particularly if treatment is given with other CNS sedating agents like opioids
  • Antipsychotics
    • May be given to women who have depression with features of psychosis

Other Potential Therapies

  • Other promising treatments include the following though further studies are needed to demonstrate efficacy: Estrogen supplementation, omega-3 fatty acids, folate, S-adenosylmethionine, St. John’s wort
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