23/2/24, 14:02 Postpartum unipolar major depression: General principles of treatment - UpToDate

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Postpartum unipolar major depression: General

principles of treatment
AUTHOR: Adele Viguera, MD
SECTION EDITORS: Peter P Roy-Byrne, MD, Charles J Lockwood, MD, MHCM
DEPUTY EDITOR: David Solomon, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan 2024.

This topic last updated: May 18, 2023.

INTRODUCTION

Although the delivery of a baby is typically a happy event, some postpartum women become
depressed. Patients may manifest postpartum blues consisting of mild depressive symptoms
that are generally self-limited, or more severe syndromes such as unipolar major depression.
Untreated postpartum major depression can result in both short- and long-term negative
consequences for the mother and infant [1-4].

This topic reviews the general principles of treating postpartum unipolar major depression.
Other topics discuss choosing a specific treatment for postpartum unipolar major
depression, the clinical features and diagnosis of postpartum major depression, and the
safety of infant exposure to psychotropic drugs through lactation.

● (See "Mild to moderate postpartum unipolar major depression: Treatment".)

● (See "Severe postpartum unipolar major depression: Choosing treatment".)
● (See "Postpartum unipolar major depression: Epidemiology, clinical features,
assessment, and diagnosis".)
● (See "Safety of infant exposure to antidepressants and benzodiazepines through
breastfeeding".)
● (See "Breastfeeding infants: Safety of exposure to antipsychotics, lithium, stimulants,
and medications for substance use disorders".)

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GENERAL PRINCIPLES

Patients with postnatal depression are usually best served by a multidisciplinary team that
includes an obstetrician or internist and a psychiatrist. Communication among all of the
involved clinicians is important to give consistent messages to increase uptake of treatment.

The sections below describe some general principles and issues that are involved in treating
postpartum unipolar major depression. Information about the principles of treating unipolar
depression in the general population of adults is discussed separately. (See "Unipolar
depression in adults and initial treatment: General principles and prognosis", section on
'General principles'.)

Setting — Most women who are considering treatment for perinatal depression prefer to
receive help at their obstetrics clinic, either from the obstetrician or a mental health clinician
located at the clinic [5]. Randomized trials indicate that depressed patients, including women
with perinatal depressive symptoms, can benefit from collaborative (integrated) care that is
administered at an obstetrics and gynecology clinic [6,7]. Collaborative care involves a team
of clinicians, such as an obstetrician, case manager, and mental health specialist, who work
together to provide pharmacotherapy and/or psychotherapy.

Severely ill patients typically require hospitalization. Jointly admitting the mother and infant
to a mother-baby unit can facilitate breastfeeding and teaching parenting skills to mothers
[8]. These units also allow the treatment team to observe mother-infant interactions and to
work with the mother on improving her relationship with her child. These units are ideal;
however, more are available in Australia and Europe than the United States.

History of prior treatment — It is important to assess the benefit of previous therapies in

order to guide treatment selection for postpartum unipolar major depression. Patients who
were successfully treated with a particular psychotherapy and/or antidepressant prior to or
during pregnancy should generally receive the same therapy or drug for postpartum
depression.

Additional information about assessing patients for postpartum depression is discussed

separately. (See "Postpartum unipolar major depression: Epidemiology, clinical features,
assessment, and diagnosis", section on 'Initial evaluation'.)

Educating patients and families — For postnatal unipolar major depression, we

recommend psychoeducation for the patient and family. Although evidence for the efficacy
of psychoeducation is limited [9-11], educating patients about depression is consistent with
multiple treatment guidelines [12-14]. Psychoeducation includes information about the
symptoms and course of depression as well as treatment options. The discussion about
treating postpartum depression should include information about the potential risks of
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untreated depression for the mother, mother-infant bonding, infant attachment, child
development, and family. (See "Severe postpartum unipolar major depression: Choosing
treatment", section on 'Initial treatment'.)

In addition, patients are encouraged to get adequate rest, maintain a consistent sleep-wake
cycle, utilize supports such as doulas or night nurses, reduce stressors when possible, and
continue prepregnancy exercise routines. (See "Exercise during pregnancy and the
postpartum period", section on 'Postpartum individuals'.)

Adherence — Poor adherence is common among patients with psychiatric disorders,

including postpartum depression. Barriers to care include cost, logistics, not trusting
clinicians, and stigma [15].

Monitoring symptoms — We routinely monitor patients treated for postnatal depression,

using the self-report, 10-item Edinburgh Postnatal Depression Scale ( figure 1A-B) [16]. The
scale can be completed in less than five minutes in the waiting room immediately before
seeing the clinician. Although the instrument was originally developed as a screening tool,
we find it is also useful for monitoring response to treatment [17]. Items asking about the
somatic symptoms of depression such as sleep and appetite are not included in the scale
because these symptoms are common in postpartum women who are not depressed [18].
The scale is acceptable to most women and clinicians [19], easy to score, and is available in
over 50 languages [20]. Responses are scored 0, 1, 2, or 3, with a maximum score of 30. In
studies that evaluated the instrument as a screening tool, scores ≥12 or 13 identified most
women with major depression. However, many studies used a cutoff score of ≥10 [21].

A reasonable alternative to the Edinburgh Postnatal Depression Scale is the self-report, nine-
item Patient Health Questionnaire ( table 1). However, the Patient Health Questionnaire
includes items about appetite, energy, and sleep, which may reflect the physical effects of
the puerperium rather than depression [22].

General information about monitoring patients during treatment of depression is discussed

separately. (See "Using scales to monitor symptoms and treat depression (measurement
based care)".)

In addition, nursing infants of mothers who are taking antidepressant medications should be
monitored by the pediatrician. (See "Safety of infant exposure to antidepressants and
benzodiazepines through breastfeeding", section on 'Monitoring'.)

Prescribing antidepressants — Patients with postpartum major depression who want to

breastfeed their babies need to weigh various risks when deciding whether to use
antidepressant medications. If the demands of breastfeeding are overwhelming the mother
and interfering with recovery from childbirth, maternal well-being should be prioritized over
breastfeeding.
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In addition, the potential risks of untreated depression need to be weighed against infant
exposure to antidepressant medications. There is a general consensus that the benefits of
antidepressants outweigh the potential risks to the infant, which are regarded as low. As an
example, most SSRIs pass into breast milk at a dose less than 10 percent of the maternal
level and are generally considered compatible with breastfeeding of healthy, full-term infants
[23]. (See "Severe postpartum unipolar major depression: Choosing treatment", section on
'Initial treatment' and "Safety of infant exposure to antidepressants and benzodiazepines
through breastfeeding", section on 'Selective serotonin reuptake inhibitors'.)

For postpartum patients who were treated with antidepressants during pregnancy up until
delivery and are maintained on their medication, we continue to prescribe the same dose
that was prescribed before delivery [24]. Patients are monitored for adverse effects that may
occur because of postpartum pharmacokinetic changes (eg, altered serum medication
concentrations) that stem from decreased plasma volume and decreased hepatic enzyme
activity.

For patients who initiate pharmacotherapy after delivery, drug doses are similar to those
used in the general population of patients with depression. For patients who were
successfully treated with antidepressants before pregnancy, stopped treatment during
pregnancy, and then resume the antidepressant after delivery, the target dose during the
postpartum period is the same dose that kept the patient well prior to pregnancy.

Patients who start or resume antidepressants after delivery and are concerned about
adverse effects can be started on lower doses (eg, sertraline 25 mg/day rather than 50
mg/day). Many patients will require the dose to be titrated up; one randomized trial found
that among patients who remitted with sertraline, the dose generally ranged between 100
and 200 mg/day [17]. Monotherapy at higher doses is preferred over medication
combinations at lower doses [25]. Additional information about antidepressant doses is
discussed separately. (See "Unipolar major depression in adults: Choosing initial treatment",
section on 'Dose' and "Unipolar major depression in adults: Choosing initial treatment".)

Managing nonresponse — If patients with postnatal unipolar major depression do not

respond to initial treatment, we suggest the following steps:

● Verify that the patient has unipolar major depression rather than a different condition
such as bipolar major depression. (See "Postpartum unipolar major depression:
Epidemiology, clinical features, assessment, and diagnosis", section on 'Differential
diagnosis' and "Unipolar depression in adults: Assessment and diagnosis", section on
'Differential diagnosis'.)

● Ask about adherence with treatment because nonadherence is common during

treatment of psychiatric disorders; improving adherence with pharmacotherapy or

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psychotherapy homework can convert nonresponders to responders.

● Determine whether there are significant life stressors (eg, nonsupportive partner) that
need to be addressed.

● Establish if comorbid psychopathology (eg, anxiety disorder, personality disorder, or

substance use disorder) is present. If a disorder other than major depression is more
salient, treatment should refocus upon the primary problem. Comorbidity in patients
with unipolar major depression is discussed separately. (See "Unipolar depression in
adults: Clinical features", section on 'Psychiatric'.)

Referrals — Primary care clinicians and obstetricians often manage postnatal unipolar major
depression. However, the diagnosis may not be clear or these clinicians may not be
comfortable managing postpartum depression and thus refer patients to psychiatrists;
referrals are also made if requested by patients. In addition, referral is usually indicated for
patients with:

● Severe depression (see "Severe postpartum unipolar major depression: Choosing

treatment", section on 'Severity of illness')

● Bipolar major depression (see "Bipolar disorder in adults: Assessment and diagnosis",
section on 'Unipolar major depression')

● Suicidal ideation or behavior (see "Suicidal ideation and behavior in adults")

● Aggressive behavior (see "Assessment and emergency management of the acutely

agitated or violent adult")

● Psychotic features (eg, delusions or hallucinations) (see "Unipolar major depression

with psychotic features: Epidemiology, clinical features, assessment, and diagnosis")

● Catatonia (see "Catatonia in adults: Epidemiology, clinical features, assessment, and

diagnosis")

● Poor judgement that places the patient or others (including the infant and other
children) at imminent risk of harm

● Psychiatric comorbidity, such as anxiety disorders, eating disorders, or substance use

disorders

● Nonresponse to initial treatment

In addition, primary care clinicians and obstetricians may refer patients who are currently
euthymic but have a prior history of major depression or other psychiatric disorders for a
consultation with an expert in perinatal psychiatry. Referral to social work may also be
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appropriate; indications include problematic social circumstances, such as intimate partner

violence, poverty, unemployment, or homelessness. Social workers can facilitate treatment
uptake and coordination of care.

One review found that among all new mothers, at least 2 percent were referred for
psychiatric treatment [26].

CHOOSING SPECIFIC TREATMENTS

Choosing specific treatments for postnatal unipolar major depression is discussed

separately. (See "Mild to moderate postpartum unipolar major depression: Treatment" and
"Severe postpartum unipolar major depression: Choosing treatment".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Depressive
disorders".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, “The Basics” and “Beyond the
Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

● Basics topics (see "Patient education: Depression in adults (The Basics)" and "Patient
education: Coping with high drug prices (The Basics)")

● Beyond the Basics topics (see "Patient education: Depression in adults (Beyond the
Basics)" and "Patient education: Coping with high prescription drug prices in the United
States (Beyond the Basics)")

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SUMMARY

● Setting – Most women who are considering treatment for perinatal depression prefer
to receive help at their obstetrics clinic, either from the obstetrician or a mental health
clinician located at the clinic. (See 'Setting' above.)

● Education – We educate patients with postnatal unipolar major depression and

families about the symptoms of depression, treatment options, and the potential risks
of untreated depression. In addition, we encourage patients to get adequate rest,
maintain a consistent sleep-wake cycle, utilize supports, reduce stressors when
possible, and continue prepregnancy exercise routines. (See 'Educating patients and
families' above.)

● We suggest routinely monitoring symptoms of perinatal depression during treatment

with the self-report, 10-item Edinburgh Postnatal Depression Scale ( figure 1A-B).
However, a reasonable alternative is self-report, nine-item Patient Health Questionnaire
( table 1). (See 'Monitoring symptoms' above.)

● Patients with postpartum major depression who want to breastfeed their babies need
to weigh various risks when deciding whether to use antidepressant medications. If the
demands of breastfeeding are overwhelming the mother, maternal well-being should
be prioritized over breastfeeding.

In addition, the potential risks of untreated depression need to be weighed against the
risks of infant exposure to antidepressant medications. There is a general consensus
that the benefits of antidepressants outweigh the potential risks to infants, which are
regarded as low. As an example, most SSRIs pass into breast milk at a dose less than 10
percent of the maternal level and are generally considered compatible with
breastfeeding of healthy, full-term infants.

For patients who were treated with antidepressants during pregnancy up until delivery
and are maintained on their medication, we continue to prescribe the same dose that
was prescribed before delivery. Patients are monitored for adverse effects that may
occur due to pharmacokinetic changes after delivery. For patients who initiate
pharmacotherapy after delivery, drug doses are similar to those used in the general
population of patients with depression. For patients who were successfully treated with
antidepressants before pregnancy, stopped treatment during pregnancy, and then
resume the antidepressant after delivery, the target dose during the postpartum period
is the same dose that kept the patient well prior to pregnancy. (See 'Prescribing
antidepressants' above.)

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● If patients with postnatal unipolar major depression do not respond to initial treatment,
we suggest verifying the diagnosis (eg, rule out bipolar disorder), asking about
adherence, and determining whether there are life stressors and/or comorbid
psychiatric disorders that require attention. (See 'Managing nonresponse' above.)

● Referrals – Although primary care clinicians and obstetricians can treat postpartum
patients who are depressed, many patients are referred to psychiatrists, especially for
more complex clinical presentations, such as severe major depression, suicidal ideation
and behavior, psychotic features, and nonresponse to initial treatment. (See 'Referrals'
above.)

● Selecting a specific treatment depends in part upon the severity of the depressive
syndrome. (See "Mild to moderate postpartum unipolar major depression: Treatment"
and "Severe postpartum unipolar major depression: Choosing treatment".)

Use of UpToDate is subject to the Terms of Use.

REFERENCES

1. Stein A, Pearson RM, Goodman SH, et al. Effects of perinatal mental disorders on the
fetus and child. Lancet 2014; 384:1800.
2. Howard LM, Piot P, Stein A. No health without perinatal mental health. Lancet 2014;
384:1723.
3. Howard LM, Molyneaux E, Dennis CL, et al. Non-psychotic mental disorders in the
perinatal period. Lancet 2014; 384:1775.

4. Grigoriadis S, VonderPorten EH, Mamisashvili L, et al. The impact of maternal

depression during pregnancy on perinatal outcomes: a systematic review and meta-
analysis. J Clin Psychiatry 2013; 74:e321.
5. Goodman JH. Women's attitudes, preferences, and perceived barriers to treatment for
perinatal depression. Birth 2009; 36:60.
6. Melville JL, Reed SD, Russo J, et al. Improving care for depression in obstetrics and
gynecology: a randomized controlled trial. Obstet Gynecol 2014; 123:1237.
7. Grote NK, Katon WJ, Russo JE, et al. COLLABORATIVE CARE FOR PERINATAL DEPRESSION
IN SOCIOECONOMICALLY DISADVANTAGED WOMEN: A RANDOMIZED TRIAL. Depress
Anxiety 2015; 32:821.
8. Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. Am J Obstet
Gynecol 2009; 200:357.
9. National Institute for Health and Care Excellence (NICE). Antenatal and postnatal mental
health: clinical management and service guidance. NICE clinical guideline 192. Decembe

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23/2/24, 14:02 Postpartum unipolar major depression: General principles of treatment - UpToDate

r 2014. http://www.nice.org.uk/guidance/cg192 (Accessed on January 28, 2016).

10. Ngai FW, Chan SW, Ip WY. The effects of a childbirth psychoeducation program on
learned resourcefulness, maternal role competence and perinatal depression: a quasi-
experiment. Int J Nurs Stud 2009; 46:1298.

11. Hayes BA, Muller R, Bradley BS. Perinatal depression: a randomized controlled trial of an
antenatal education intervention for primiparas. Birth 2001; 28:28.

12. American Psychiatric Association. Practice Guideline for the Treatment of Patients with
Major Depressive Disorder, Third Edition (supplement). Am J Psychiatry 2010; 167:1.
13. American Psychiatric Association. Practice Guideline for the Treatment of Patients with
Major Depressive Disorder, Third Edition. October, 2010. http://psychiatryonline.org/gui
delines (Accessed on February 13, 2016).
14. National Institute for Health and Care Excellence (NICE). Depression: The Treatment and
Management of Depression in Adults (Updated Edition). Clinical Guideline 90. October, 2
009. http://www.nice.org.uk/guidance/cg90 (Accessed on February 13, 2016).
15. Stuart S, Koleva H. Psychological treatments for perinatal depression. Best Pract Res Clin
Obstet Gynaecol 2014; 28:61.
16. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the
10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150:782.

17. Kim DR, Epperson CN, Weiss AR, Wisner KL. Pharmacotherapy of postpartum
depression: an update. Expert Opin Pharmacother 2014; 15:1223.

18. Committee on Obstetric Practice. The American College of Obstetricians and

Gynecologists Committee Opinion no. 630. Screening for perinatal depression. Obstet
Gynecol 2015; 125:1268.
19. El-Den S, O'Reilly CL, Chen TF. A systematic review on the acceptability of perinatal
depression screening. J Affect Disord 2015; 188:284.
20. Cox J, Holden J, Henshaw C. Perinatal Mental Health: The Edinburgh Postnatal Depressio
n Scale (EPDS) Manual, Second Edition, RCPsych Publications, London 2014.
21. Wisner KL, Sit DK, McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses
in postpartum women with screen-positive depression findings. JAMA Psychiatry 2013;
70:490.
22. Vigod SN, Wilson CA, Howard LM. Depression in pregnancy. BMJ 2016; 352:i1547.

23. Stewart DE, Vigod S. Postpartum Depression. N Engl J Med 2016; 375:2177.

24. Deligiannidis KM, Byatt N, Freeman MP. Pharmacotherapy for mood disorders in
pregnancy: a review of pharmacokinetic changes and clinical recommendations for
therapeutic drug monitoring. J Clin Psychopharmacol 2014; 34:244.

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23/2/24, 14:02 Postpartum unipolar major depression: General principles of treatment - UpToDate

25. ACOG Committee on Practice Bulletins--Obstetrics. ACOG Practice Bulletin: Clinical

management guidelines for obstetrician-gynecologists number 92, April 2008 (replaces
practice bulletin number 87, November 2007). Use of psychiatric medications during
pregnancy and lactation. Obstet Gynecol 2008; 111:1001. Reaffirmed Obstet Gynecol
2018; 131:185. Reaffirmed 2020.
26. Cantwell R, Clutton-Brock T, Cooper G, et al. Saving Mothers' Lives: Reviewing maternal
deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential
Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118 Suppl 1:1.
Topic 108715 Version 5.0

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GRAPHICS

Appendix A: Edinburgh Postnatal Depression Scale

Reproduced from: Cox JL, Holden JM, Sagovsky R. Detection of Postnatal Depression: Development of the 10-item Edinburgh
Postnatal Depression Scale. Br J Psychiatry 1987; 150:782. Copyright © 1987 British Journal of Psychiatry.

Graphic 67741 Version 3.0

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Appendix A: Edinburgh Postnatal Depression Scale (EPDS) (continued)

We suggest a cutoff score of 11, which appears to maximize sensitivity plus specificity in screening for
postpartum depression. Women who report depressive symptoms without suicidal ideation or major
functional impairment (or score between 5 and 9 on the EPDS) should be re-evaluated within one
month.

Reproduced from: Cox JL, Holden JM, Sagovsky R. Detection of Postnatal Depression: Development of the 10-item Edinburgh
Postnatal Depression Scale. Br J Psychiatry 1987; 150:782. Copyright © 1987 British Journal of Psychiatry.

Graphic 81407 Version 6.0

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PHQ-9 depression questionnaire

Name: Date:

Over the last 2 weeks, how often have you been Not at Several More Nearly
bothered by any of the following problems? all days than every
half day
the
days

Little interest or pleasure in doing things 0 1 2 3

Feeling down, depressed, or hopeless 0 1 2 3

Trouble falling or staying asleep, or sleeping too 0 1 2 3

much

Feeling tired or having little energy 0 1 2 3

Poor appetite or overeating 0 1 2 3

Feeling bad about yourself, or that you are a failure, 0 1 2 3

or that you have let yourself or your family down

Trouble concentrating on things, such as reading the 0 1 2 3

newspaper or watching television

Moving or speaking so slowly that other people could 0 1 2 3

have noticed? Or the opposite, being so fidgety or
restless that you have been moving around a lot
more than usual.

Thoughts that you would be better off dead, or of 0 1 2 3

hurting yourself in some way

Total ___ = ___ + ___ + ___ + ___

PHQ-9 score ≥10: Likely major depression

Depression score ranges:

5 to 9: mild

10 to 14: moderate

15 to 19: moderately severe

≥20: severe

If you checked off any problems, how difficult Not Somewhat Very Extremel
have these problems made it for you to do your difficult difficult difficult difficult
work, take care of things at home, or get along at all
___ ___ ___
with other people? ___

PHQ: Patient Health Questionnaire.

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Developed by Drs. Robert L Spitzer, Janet BW Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer,
Inc. No permission required to reproduce, translate, display or distribute.

Graphic 59307 Version 12.0

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