Evidence-Based Reviews

Postpartum depression: Is there an Andrea Yates in your practice?

Current Psychiatry. 2002 May;1(5):22-29

References

1. O’Hara MW, Swain AM. Rates and risk of postpartum depression: a meta-analysis. Int Rev Psychiatry 1996;8:37-54.

2. Weinberg MK, Tronick EZ. The impact of maternal psychiatric illness on infant development. J Clin Psychiatry 1998;59(suppl 2):53-61.

3. O’Hara MW. Social support, life events, and depression during pregnancy and the puerperium. Arch Gen Psychiatry 1986;43:569-73.

4. Beck CT. Predictors of postpartum depression: an update. Nursing Res 2001;50(5):275-85.

5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision. Washington, DC, American Psychiatric Association, 2000.

6. Evins GG, Theofrastous JP, Galvin SL. Postpartum depression: a comparison of screening and routine clinical evaluation. Am J Obstet Gynecol 2000;182(5):1080-2.

7. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10 –item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-6.

8. Beck CT, Gable RK. Further validation of the postpartum depression screening scale. Nursing Res 2001;50(3):155-64.

9. Appleby L, Warner R, Whitton A, Faragher B. A controlled study of fluoxetine and cognitive-behavioural counselling in the treatment of postnatal depression. BMJ 1997;314(7085):932-6.

10. Stuart S, O’Hara MW. Interpersonal psychotherapy for postpartum depression: a treatment program. J Psychother Pract Res 1995;4:18-29.

11. O’Hara MW, Stuart S, Gorman LL, Wenzel A. Efficacy of interpersonal psychotherapy for postpartum depression. Arch Gen Psychiatry 2000;57(11):1039-45.

12. Misri S, Kostaras X, Fox D, Kostaras D. The impact of partner support in the treatment of postpartum depression. Can J Psychiatry 2000;45(6):554-8.

13. Burt VK, Suri R, Altshuler L, et al. The use of psychotropic medications during breast-feeding. Am J Psychiatry 2001;158(7):1001-9.

14. Birnbaum CS, Cohen LS, et al. Serum concentrations of antidepressants and benzodiazepines in nursing infants: a case series (electronic article). Pediatrics 1999;104(1):www.pediatrics.org/cgi/content/full/104/1/e11

15. Lester BM, Cucca J, Andreozzi L, et al. Possible association between fluoxetine hydrochloride and colic in an infant. J Am Acad Child Adolesc Psychiatry 1993;32(6):1253-5.

16. Chambers CD, Anderson PO, Thomas RG, et al. Weight gain in infants breastfed by mothers who take fluoxetine (electronic article). Pediatrics 1999;104(5):http://www.pediatrics.org/cgi/content/full/104/5/e61

17. Epperson CN, Anderson GM, McDougle CJ. Sertraline and breast feeding (letter). N Engl J Med 1997;336(16):1189-90.

18. Wisner KL, Perel JM, Blumer J. Serum sertraline and n-desmethylsertraline levels in breast-feeding mother-infant pairs. Am J Psychiatry 1998;155(5):690-2.

19. Epperson N, Czarkowski KA, Ward-O’Brien D, et al. Maternal sertraline treatment and serotonin transport in breast-feeding mother-infant pairs. Am J Psychiatry 2001;158(10):1631-7.

20. Misri S, Kim J, Riggs KW, Kostaras X. Paroxetine levels in postpartum depressed women, breast milk, and infant serum. J Clin Psychiatry 2000;61(11):828-32.

21. Wright S, Dawling S, Ashford JJ. Excretion of fluvoxamine in breast milk (letter). Br J Clin Pharmacol 1991;31:209.-

22. Piontek CM, Wisner KL, Perel JM, Peindl KS. Serum fluvoxamine levels in breastfed infants. J Clin Psychiatry 2001;62(2):111-3.

23. Wisner KL, Perel JM, Foglia JP. Serum clomipramine and metabolite levels in four nursing mother-infant pairs. J Clin Psychiatry 1995;56(1):17-20.

24. Altshuler LL, Burt VK, McMullen M, Hendrick V. Breastfeeding and sertraline: a 24-hour analysis. J Clin Psychiatry 1995;56(6):243-5.

25. Briggs GG, Samson JH, Ambrose PJ, Schroeder DH. Excretion of bupropion in breast milk. Ann Pharmacother 1993;27(4):431-3.

26. Verbeeck RK, Ross SG, McKenna EA. Excretion of trazodone in breast milk. Br J Clin Pharmacol 1986;22:367-70.

27. Yapp P, Ilett KF, Kristensen JH, et al. Drowsiness and poor feeding in a breast-fed infant: association with nefazodone and its metabolites. Ann Pharmacother 2000;34(11):1269-72.

28. Illett KF, Hackett LP, Dusci LJ, et al. Distribution and excretion of venlafaxine and O-desmethylvenlafaxine in human milk. Br J Clin Pharmacol 1998;45:459-62.

29. Hill RC, McIvor RJ, Wojnar-Horton RE, et al. Risperidone distribution and excretion in human milk: case report and estimated infant exposure during breast-feeding (letter). J Clin Psychopharmacol 2000;20(2):285-6.

30. Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiat 1994;45:444-50.

Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) are used most commonly to treat PPD. Monoamine oxidase inhibitors (MAOIs) are not recommended as they have been reported to exacerbate hypertension, and their extensive interaction profiles with food and other medications can complicate treatment. Further, only limited evidence is available on the effects of MAOIs during pregnancy and the postpartum period.

Box 1

HOW TO ADMINISTER THE EDINBURGH POSTNATAL DEPRESSION SCALE

Ask the mother to underline the response that comes closest to how she has been feeling in the previous 7 days.
All 10 items must be completed.
Avoid the possibility of the mother discussing her answers with others.
The mother should complete the scale herself, unless she has limited English or difficulty with reading.
The EPDS may be used at 6 to 8 weeks postnatal. A visit to the child health clinic, a postnatal check-up, or a home visit may provide suitable opportunities for its completion.

As you have recently had a baby, we would like to know how you are feeling. Please CHECK the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

I have been able to laugh and see the funny side of things.
I have looked forward with enjoyment to things.
* I have blamed myself unnecessarily when things went wrong.
I have been anxious or worried for no good reason.
* I have felt scared or panicky without a good reason.
* Things have been getting on top of me.
* I have been so unhappy that I have had difficulty sleeping.
* I have felt sad or miserable.
* I have been so unhappy that I have been crying.
* The thought of harming myself has occurred to me.

Responses to statements 1, 2, and 4 are scored 0, 1, 2, and 3 according to increasing severity of symptoms, and statements marked with an asterisk (*) are reverse-scored (3, 2, 1, and 0). Total score is calculated by adding the scores of all 10 items. A score of 12 or 13 has been found to identify most women with a diagnosis of PPD.

Adapted from Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-6.

Table 3

SSRI DRUG THERAPY FOR POSTPARTUM DEPRESSION

Medication	Starting daily dosage (mg)	Maximum daily dosage (mg)	Precautions
Fluoxetine	10	80	Very long half-life of active metabolite may lead to accumulation in infants Inform parents of possible side effects, and include a pediatrician in routine clinical evaluations of the infant
Sertraline	25	300	Benign neonatal sleep myoclonus has been documented in one case of sertraline exposure during breast-feeding Inform parents of possible side effects, and include a pediatrician in routine clinical evaluations of the infant
Paroxetine	10	60	No adverse effects have been reported
Fluvoxamine	50	300	Data limited
Citalopram	10	60	Data limited

Use of SSRIs

The literature on use of SSRIs in lactating women has expanded rapidly in recent years (Table 3). But because these agents have been on the market a relatively short time, the long-term developmental effects of infants’ exposure to SSRIs through breast milk have yet to be evaluated. Fluoxetineis the SSRI with the most published data on use by breast-feeding women. To date, nine studies have reported the outcomes of a total of 57 infants exposed to fluoxetine during breast feeding.^13,14 Norfluoxetine, the potent metabolite of fluoxetine, has a long half-life that may predispose to accumulation in the serum of nursing infants.

Adverse effects such as colic, fussiness, crying, seizure activity, and reduced weight gain have been reported in two cases.^15,16 The remaining studies on the use of fluoxetine by breast-feeding women have reported low drug levels in both mothers and infants, and no other adverse effects have been documented.

Sertraline. To date, seven published reports of sertraline exposure have documented 46 infant outcomes. In all of these reports, sertraline and its weak metabolite have been detected in low or trace amounts in the sera of nursing infants.^13,14,17-19 A recent study of 19 breast-feeding mother-infant pairs found that platelet serotonin uptake in these infants was unaltered, despite the detection of low serum levels of sertraline and its metabolite.¹⁹

Paroxetine. Paroxetine is also excreted into the breast milk of lactating women, although—unlike the other SSRI medications—the agent does not have an active metabolite that could potentially accumulate in the serum of nursing infants. Five reports totaling 60 infant outcomes have been published regarding paroxetine exposure during breast feeding. Low or undetectable serum levels were reported in all of the infants, and no adverse effects were noted.^13,14,20

Fluvoxamine, citalopram. Two small case studies of fluvoxamine have each reported very low drug levels in breast milk and no adverse events in the exposed infants.^21,22 Only three case studies examining five infants exposed to citalopram during breast feeding have been published.¹³ As information is limited regarding the effects of these medications on nursing infants, caution is advised when prescribing either agent to breast-feeding women.