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.

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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.

Use of TCAs and other antidepressants

TCAs are useful for treating PPD when SSRIs have failed or the patient has shown a previous good response to TCAs. All TCAs are excreted into breast milk in low concentrations, and a wide range of infant serum levels have been reported.

No adverse effects have been documented for infant exposure to amitriptyline, clomipramine, desipramine, imipramine, or nortriptyline.^13,14,23,24 The active metabolite of doxepin has the longest half-life (37 hours) among the TCAs and may be potentially hazardous to nursing infants because of high serum accumulations. Because two reports have associated doxepin exposure with respiratory distress, poor sucking, drowsiness, and vomiting in infants, the use of medications with a shorter half-life and better-documented effects in infants is recommended.¹³

Limited evidence is available on the use of newer antidepressants such as bupropion, trazodone, and nefazodone by breast-feeding women.^25-27 When possible, therefore, such patients should be prescribed an antidepressant with more documented use in breast-feeding mothers.

Venlafaxine is a newer antidepressant that inhibits reuptake of both serotonin and norepinephrine. The only case report published to date regarding venlafaxine levels in nursing infants found high drug levels in the sera of three exposed infants but no adverse effects.²⁸

Use of antipsychotics, ECT

Postpartum psychosis is rare and requires immediate intervention. Treatment with antipsychotics is one of the most effective methods for controlling a psychotic episode. Most women with postpartum psychosis will be too disorganized to consider breast-feeding, but for those who may wish to breast-feed, a discussion with her partner about infant exposure issues is recommended.

Effects of infant exposure through breast milk to the typical antipsychotics (e.g., chlorpromazine, trifluoperazine, haloperidol) include drowsiness, lethargy, and possible developmental delays.¹³ Nursing infants should be monitored for sedation and other adverse effects during long-term maternal use of these medications.

Evidence on the use of atypical antipsychotics during breast-feeding is limited. One report described cardiomegaly, jaundice, and sedation in one of three infants exposed to olanzapine through breast milk. But the effects could not be attributed directly to breast milk, as that infant was exposed both in utero and during breast-feeding.¹³

One report of a nursing infant exposed to risperidone indicated no adverse effects,²⁹ and there is no published data on quetiapine use during breast-feeding.

ECT If the patient with psychotic PPD cannot tolerate or does not respond to antipsychotic medication, electroconvulsive therapy (ECT) may be indicated. ECT in the postpartum period is safe for both mother and infant. It is particularly useful when rapid treatment is imperative, such as severe depression with psychotic symptoms, acute mania, and in mothers who are at risk for suicide or infanticide.³⁰

Management guidelines for PPD

Based on our experience and the available evidence, we offer these recommendations to psychiatrists managing patients with PPD:

During the initial psychiatric assessment, use screening tools such as the EPDS or the PDSS to assist with diagnosis and to identify symptom patterns.
Next, schedule a conjoint visit with the patient’s partner, family members, and/or social supports. Provide educational materials about PPD and exchange information about treatment options to help the patient make informed decisions. Reading lists, appropriate research articles, lists of local resources, and Web sites can increase awareness about PPD and drive home the importance of compliance with treatment.
If pharmacotherapy is to be used, discuss honestly and openly the medication’s benefits and potential risks for both mother and infant in the short and long term.
Outline a treatment plan with the patient and her partner. This should include 6 weeks of treatment during the acute phase, as well as maintenance and long-term therapy.
If applicable, discuss with the woman and her partner pregnancy planning during pharmacotherapy. In women who experience repeated episodes of depression, discontinuing an antidepressant during pregnancy almost always results in relapse of depressive symptoms.

Related resources

Misri S. Shouldn’t I Be Happy? Emotional problems of pregnant and postpartum women. . New York: Free Press, 1995.
Sichel D, Driscoll JW. Women’s moods: What every woman must know about hormones, the brain, and emotional health. . New York: William Morrow & Co., 1999.
Depression After Delivery, Inc. www.depressionafterdelivery.com or 1-800-944-4773 (4PPD)
Postpartum Support International. www.postpartum.net
Pacific Postpartum Support Society. www.postpartum.org

Drug brand names

Amitriptyline • Elavil
Bupropion • Wellbutrin
Citalopram • Celexa
Clomipramine • Anafranil
Desipramine • Norpramin
Fluoxetine • Prozac
Fluvoxamine • Luvox
Imipramine • Tofranil
Nefazodone • Serzone
Nortriptyline • Aventyl
Paroxetine • Paxil
Sertraline • Zoloft
Trazodone • Desyrel
Venlafaxine • Effexor

Disclosure

Dr. Misri reports that she receives grant/research support from and serves on the speaker’s bureau of GlaxoSmithKline Canada, receives research/grant support from Wyeth-Ayerst Pharmaceuticals, and has lectured for Eli Lilly & Co., AstraZeneca, and Janssen-Ortho.