Postpartum depression (PPD) is a surprisingly common condition, affecting 10%–20% of new mothers within the first year after giving birth. The rate is even higher among those with prior history of PPD—such patients face up to a 50% risk of a subsequent PPD episode (Wisner KL et al, Am J Psychiatry 2004;161(7):1290–1292). 

In about half the cases of PPD, the depressive episode starts during pregnancy or even prior to conception. True PPD, ie, depression with onset in the first few weeks postpartum, tends to be more severe and refractory. While most cases eventually resolve, at least 30% remain depressed throughout and beyond the first year postpartum if untreated (Vliegen N et al, Harv Rev Psychiatry 2014;22(1):1–22). 

What are the classic symptoms of PPD?

Symptoms of PPD are similar to those of major depressive disorder (MDD): 

• Low mood 
• Anhedonia 
• Excessive guilt (often centered on perceived parenting failures) 
• Changes in sleep and appetite 
• Decreased concentration, motivation, and energy
• Feeling of disconnection (eg, poor bonding with the infant) 

When severe, individuals may experience thoughts of suicide. Do not assume that a new mother’s sense of responsibility as a parent will protect against suicidal thoughts—suicide accounts for 5% of all maternal deaths in the first year postpartum (Goldman-Mellor S et al, Am J Obstet Gynecol 2019;221(5):489.e1–489.e9).

Screening for PPD 

Screening for PPD can be challenging as certain symptoms, like disrupted sleep and exhaustion, overlap with normative experiences of new parents. To avoid overlooking PPD, I recommend universal screening with validated tools like the Edinburgh Postnatal Depression Scale (EPDS), which can be used at least once early during pregnancy and again at around six to nine weeks postpartum. The EPDS is a 10-question self-reported questionnaire validated for use in pregnancy and postpartum (Levis B et al, BMJ 2020;371:m4022). A score of 10 or higher flags elevated concern for depression, detecting 85% of perinatal depression cases. However, the EPDS is not diagnostic; it doesn’t distinguish between unipolar and bipolar depression. Ultimately, over a third of individuals with positive screens on the EPDS are found to have bipolar depression, so use the screening results as a conversation opener for a clinical assessment rather than moving directly to discussion of treatment options (Clark CT et al, Depress Anxiety 2015;32(7):518–526). 

Treatment options 

After making a diagnosis of PPD, how do you select a treatment plan? Choose treatment options in the same way that you do for MDD in the general population: based on the clinical severity of the symptoms and on individual patient factors. 

Nonpharmacologic approaches 

Emphasize sleep preservation, as even a few contiguous days of protected sleep produce a large and durable antidepressant effect. Engage your patient’s support system when “prescribing sleep.” To allow longer stretches of protected sleep, I encourage my patients to have their partners feed the baby with pumped milk or formula. 

Encourage individual and group psychotherapy, as well as hospital- or organization-based peer support groups. Postpartum Support International offers a particularly wide array of free, virtual, facilitator-led peer support groups for various clinical diagnoses and patient identities (www.tinyurl.com/ywkefm38). I stay away from recommending informal social media–based parenting groups as they don’t appear to reliably help and some evidence suggests they may exacerbate anxiety. 

Pharmacologic approaches

Select antidepressant medications based on past response, side effects, cost, etc. Inform your patients that breastfeeding is not a contraindication for starting or continuing an antidepressant, as adverse events are extremely rare (Pinheiro E et al, Arch Womens Ment Health 2015;18(2):139–146; also see our Q&A with Dr. Karen Horst in this issue).

Sertraline is often favored due to undetectably low levels in breastfeeding infants (Pinheiro et al, 2015), but don’t switch from an effective regimen to sertraline, as it may destabilize the parent’s mental health. Sometimes patients want to know when antidepressant levels peak in breast milk so they can “pump and dump” to minimize the baby’s exposure, but all this does is waste milk. 

Intravenous brexanolone recently became the first medication to receive FDA approval specifically for PPD. It’s a neuroactive steroid (and progesterone metabolite) that works quickly, with symptoms improving in as little as three days (Meltzer-Brody S et al, Lancet 2018;392(10152):1058–1070). However, brexanolone requires a 60-hour infusion in a health care setting, and physicians must enroll the patient in a REMS program due to safety concerns of excessive sedation and hypoxia.

Zuranolone, a neurosteroid similar to brexanolone, received FDA approval as the first oral medication for PPD in August 2023. A 14-day course of zuranolone significantly improved depressive and anxiety symptoms in a recent study of new mothers with PPD (Deligiannidis KM et al, J Clin Psychiatry 2023;84(1):22m14475).

Additional treatment considerations

• Neuromodulation approaches like transcranial magnetic stimulation and ECT can be effective for PPD, so keep them in your list of treatment options.
• Severe cases may require partial hospitalization or inpatient psychiatric hospitalization. Consider perinatal-focused partial hospital programs or inpatient units in your area (www.tinyurl.com/mrxk7dnh).
• Be flexible with telehealth visits or allowing infants at appointments, as new parents may have temporary driving restrictions (eg, due to being on opioids after cesarean section) or difficulties arranging childcare.

CARLAT VERDICT