Management

Psychological and social measures to bring about changes in circumstances are as important as antidepressants:

• rally members of the family and the community
• encourage patient to be open about the problem to draw in support - it is not realistic to expect a young mother to be single-handedly totally responsible for a new baby
• review regularly until coping well
• liaise with health visitor, the family and encourage contact with support groups
• there is evidence that brief psychological therapy, usually based on cognitive-behavioural therapy or non-directive counselling, is an effective treatment for postnatal depression (1)
• UK national perinatal guidance recommends treatment for postnatal depression within a stepped-care model, with antidepressant treatment being recommended for women with more severe depression, with or without combined treatment with psychological therapy (1)
• SSRIs have been the most commonly prescribed antidepressants during pregnancy and the postnatal period (2)

Antidepressant treatment

• there is evidence of the benefit of using the SSRIs in postnatal depression (2)
  • fluoxetine or paroxetine are likely to be of benefit in postnatal depression (2)
• the use of antidepressants during breast feeding is described in the menu item
• a systematic review regarding the use of antidepressants in postnatal depression has been undertaken (2)
  • remains limited evidence regarding the effectiveness and safety of antidepressants in the management of postnatal depression, particularly for those with more severe depression
    • found low-certainty evidence that SSRI antidepressants may be more effective in treating postnatal depression than placebo as measured by response and remission rates. However, the low certainty of the evidence suggests that further research is very likely to have an important impact on our effect estimate
    • in clinical practice, the findings of this review need to be contextualised by the extensive broader literature on antidepressants in the general population and perinatal clinical guidance, to inform an individualised risk-benefit clinical decision

If the mother uses antidepressants, observation of the neonate is recommended and breastfeeding encouraged (3)

Hormonal therapy is controversial. This is described in the menu item.

Reference:

1. National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance. Clinical guideline [CG192]. Published date: December 2014. Last updated: February 2020. London: NICE, 2014.
2. Brown JVE, Wilson CA, Ayre K, et al. Antidepressant treatment for postnatal depression. Cochrane Database Syst Rev. 2021 Feb 13;2(2):CD013560.
3. Molenaar NM, Kamperman AM, Boyce P, et al. Guidelines on treatment of perinatal depression with antidepressants: an international review. Aust N Z J Psychiatry. 2018 Apr;52(4):320-7.