ABM Clinical Protocol #18: Use of Antidepressants in Breastfeeding Mothers

Spectrum of disease

There has been controversy about whether PPD is a distinct entity. In the Diagnostic and Statistical Manual of Mental Disorders , 4th and 5th editions (DSM-IV and V, respectively), PPD is considered a subtype of major depression, and there is an associated specifier to denote onset in the postpartum period. The newer DSM-V expanded the definition of PPD to include onset of symptoms during pregnancy through 4 weeks postpartum. Diagnosis may be further complicated by other comorbid conditions, including anxiety and bipolar disorder. Postpartum mood disorders are common in the postpartum period but differ according to timing and severity of symptoms and encompass a wide range of disorders.

“Postpartum blues” is a condition characterized by emotional changes, insomnia, appetite loss, and feelings of being overwhelmed that can affect 30–80% of women. It is a transient condition that usually peaks on postpartum Day 5 and resolves by Day 10. Unlike PPD, postpartum blues does not adversely affect infant care.

“Postpartum depression” is a major depressive episode that impairs social and occupational functioning. Symptoms cause significant distress and can include suicidal ideation. If untreated, symptoms may persist beyond 14 days and can last several months to a year.

“Postpartum psychosis” is a psychiatric emergency and is characterized by paranoia, hallucinations, delusions, and suicidal ideation, with the potential risk of suicide and/or infanticide. It can occur in one to three of every 1,000 deliveries and usually has a rapid onset (within hours to a few weeks) after delivery. Women with postpartum psychosis may have a prior history of postpartum psychosis or bipolar disorder, but in some women there is no prior psychiatric history. Approximately 25–50% of women with bipolar disorder are at risk of developing postpartum psychosis.

“Postpartum intrusive thoughts” and “obsessive compulsive disorder” commonly occur in women, but with a wide range of severity of symptoms they are concerns for postpartum women. Intrusive or obsessive thoughts are unwelcome and involuntary thoughts, images, or unpleasant ideas that may become obsessions. These thoughts are usually upsetting or distressing to the woman, and they can be difficult to manage or eliminate.

Screening for PPD

Research confirms that most mothers (80%) are comfortable with the idea of being screened for depression. Internationally, guidelines and authorities recommend screening for PPD.

Although definitive evidence of benefit is limited, the American College of Obstetricians and Gynecologists recommends that clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool. For the first time, a large U.S. multicenter study of screening and follow-up care for PPD in a family practice setting has shown improved maternal outcomes at 12 months. (I) (Quality of evidence [levels of evidence I, II-1, II-2, II-3, and III] is based on the U.S. Preventive Services Task Force Appendix A Task Force Ratings and is noted throughout this protocol in parentheses.)

Most physicians and maternal/child healthcare providers recognize the detrimental effects of PPD and agree that screening new mothers is within the scope of their practice. The American Academy of Pediatrics and the U.S. Surgeon General’s Office recognize and call for the early identification and treatment of mental health disorders, including PPD. It is important that screening for PPD be done systematically globally as detection and treatment have been shown to be beneficial in many countries. (I)

Screening instruments

The screening instrument that has been most studied throughout the world is the Edinburgh Postnatal Depression Scale (EPDS). The EPDS is free, considered to be in the public domain, and available in many languages and has cross-cultural validity. It has 10 questions to be completed by the mother based on symptoms over the past 7 days and takes approximately 5 minutes to complete. There are multiple points of contact in which screening can occur. In well-childcare visits, EPDS screening could occur during the 1-, 2-, 4-, and 6-month visits. The cesarean section incision check at 2 weeks and the postpartum visit at 4–8 weeks are also important screening opportunities. The EPDS can be readily administered and has demonstrated validity to detect postpartum mood disorders at as early as 4–8 weeks postpartum. (II-3) Either a score of 10 or higher or a positive response to Question 10 about suicidal thoughts is considered positive and indicates that the mother may be suffering from a depressive illness of varying severity. (II-3) Providers caring for the infant must refer a mother with a positive screen for appropriate care.