Perinatal depression includes a major or minor depressive episode that occurs during pregnancy or in the first 12 months after delivery. It affects 1 in 7 women – making it one of the most common medical complications of the perinatal period. Untreated maternal depression is associated with poor compliance with prenatal care, increased alcohol and tobacco use, preterm birth, low birth weight, increased NICU admissions, deficits in mother-infant bonding and ultimately can have devastating effects on families. Maternal suicide now exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality in the United States. There are known risk factors for perinatal depression such as unintended pregnancy and lack of social support – but depression during pregnancy and the postpartum period can affect any woman of any socioeconomic status.
ACOG recommends that clinicians screen all women at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool.(ACOG, 2015) Note that anxiety can be a prominent feature of perinatal mood disorders. Additionally, it is critical that women with bipolar disorder be appropriately screened and referred for psychiatric care, as antidepressant monotherapy in these women may trigger mania or psychosis, and experts recommend an additional short screen for a history of mania or bipolar disorder prior to the initiation of antidepressants.
Screening alone is inadequate. Per ACOG, clinical staff in Ob/Gyn practices should be prepared to initiate medical therapy, refer patients to appropriate behavioral health resources, or both and systems should be in place to ensure follow-up. (ACOG, 2015) The majority of data regarding psychotropic medicines in pregnancy are from selective serotonin reuptake inhibitors (SSRIs). SSRIs are not considered teratogens with the exception of paroxetine, which may be associated with a small increased risk of cardiac defects. (ACOG, 2008) SSRI exposure late in pregnancy has also been linked to persistent pulmonary hypertension of the newborn, however, the absolute risk is very small (3-12 per 1000 increased from 1-2 per 1000) and prospective studies have not replicated this finding. (Eke, Saccone, & Berghella, 2016) There are newer data accumulating that SSRI exposure itself is also associated with preterm birth; however in studies that control for cofounders this finding is eliminated. Neonatal withdrawal syndrome, or ‘poor neonatal adaptation’ has been reported; symptoms are mild and transient. Breastfeeding is not contraindicated for any antidepressant. While very low levels of SSRIs have been detected in breast milk, medication exposure during lactation is considerably lower than transplacental exposure during pregnancy. In sum, while there are theoretic risks of SSRI use, patients should be reassured that the magnitude of these risks are small and the benefit of treatment far outweighs any risk in the setting of perinatal depression.
Screening for depression
- An individual and family mental health history (including any past and current medications) should be included in the intake history
- All women should be screened at least once during pregnancy or postpartum. APEC recommends screening 3 times using the Edinburgh Postnatal Depression Scale (see Appendix 1) at:
The first prenatal visit
24-28 weeks (with the BSST)
Postpartum [high-risk at 2 & 6 weeks; average risk at 6 weeks] - Patients at high-risk for PP depression include those with any prior history of depression or other mental health disorder.
Assessment of EPDS
EPDS Score | Symptoms | Treatment options | Medication | Additional |
0-9 | Limited/none | Counseling therapy
Community/social support Physical activity |
||
10-13 | Mild | Consider | Counseling therapy
Community/social support Physical activity |
|
14-18 | Moderate | Consider inpatient hospitalization when safety or ability to care for self is a concern | Recommend | Counseling therapy
Community/social support Physical activity |
≥19 | Severe | Consider inpatient hospitalization when safety or ability to care for self is a concern | Initiate | Refer for psychiatry consult in addition to counseling
Counseling therapy Community/social support Physical activity |
*adapted from MCPAP For Moms
General management of depression
A score of > 10 on the EPDS suggests a patient is depressed.
- Always consider comorbid psychiatric conditions (e.g. psychosis & substance use) and medical causes of depression (e.g. thyroid dysfunction)
- Assess best treatment options for individual patient using table above
- If antidepressant is indicated, screen for bipolar disorder prior to prescribing monotherapy SSRI
- Always refer for psychotherapy (Appendix 3: Resources) in addition to medication
Questions to screen for bipolar disorder (verbally ask these questions prior to starting SSRI monotherapy)
Initial screen:
If yes to questions 1 and/or 2, then continue to screen with question 3:
- Some people have periods lasting several days or longer when they feel much more excited and full of energy than usual. Their minds go too fast. They talk a lot. They are very restless or unable to sit still and they sometimes do things that are unusual for them, such as driving too fast or spending too much money. Have you ever had a period liked this lasting several days or longer?
- Have you ever had a period lasting several days or longer when most of the time you were so irritable or grouchy that you started arguments, shouted at people, or hit people?
- People who have episodes like this often have changes in their thinking and behavior at the same time, like being more talkative, needing very little sleep, being very restless, going on buying sprees, and behaving in ways they would normally think are inappropriate. Did you ever have any of these changes during your episodes of being excited and full of energy/very irritable or grouchy?
If yes to question 3, the patient may have bipolar disorder; refer to psychiatry
If no to question 3, OK to proceed with SSRI monotherapy
Management of suicidal ideation
A positive answer on question #10 of the EPDS suggests the patient is at risk for self-harm or suicide
- Immediately assess further a positive EPDS #10 or any disclosure of suicidal ideation with the Columbia-Suicide Severity Rating Scale (Appendix 2)
- Patients needing additional psychiatric consultation should be immediately evaluated in the Emergency Department or other clinical arena where access to Psychiatric Services are available.
Antidepressant medical therapy
Attempt to schedule patient with mental health provider. Use these guidelines if you do not have a mental health provider available or while you are attempting to schedule appointment.
- If patient has a history of taking an antidepressant that helped, prescribe that antidepressant
- If no history of taking an antidepressant, use Zoloft (sertraline) as to date there is the most literature and clinical experience with this SSRI. Alternatives are Prozac (fluoxetine) or Celexa (citalopram).
- Start with half the recommended dose for 2 weeks, then increase to recommended dose as tolerated to minimize side effects (e.g. GI disturbance, dizziness, drowsiness)
- A single medication at a higher dose is favored over multiple medications
- Once treatment is initiated, reevaluate using the EPDS and clinical assessment
If no/minimal clinical improvement after 4-8 weeks:
If patient has no or minimal side effects, increase the dose
If has been on therapeutic dose for ≥ 8 weeks without response, consider switching medication versus increasing dose
If patient has side effects, switch medication
If clinical improvement and no/minimal side effects:
Reevaluate every month and at PP visit
Refer to PCP or community psych provider for ongoing care at PP visit - If an antidepressant has helped during pregnancy, continue it during breastfeeding. Sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox) are considered the safest during lactation as they have the lowest degree of translactal passage and fewest reported adverse effects compared to other anti-depressants. If starting an SSRI postpartum, choose one of these. Doses are listed as starting dose-max dose
First line treatment (SSRIs)
sertraline (Zoloft) 50-200 mg Increase in 50 mg increments |
fluoxetine (Prozac) 20-60 mg Increase in 10 mg increments |
citalopram (Celexa) 20-40 mg Increase in 10 mg increments |
escitalopram (Lexapro) 10-20 mg Increase in 10 mg increments |
Second line treatment
Consider using a second line medicine if it has worked in the past
SSRIS | paroxetine (Paxil) 20-60 mg Increase in 10 mg increments |
fluvoxamine (Luvox) 50-200 mg Increase in 50 mg increments |
SNRIs | venlafaxine (Effexor) 75-300 mg Increase in 75 mg increments |
duloxetine (Cymbalta) 30-60 mg Increase in 20 mg increments |
Other | bupropion (Wellbutrin) 300-450 mg Increase in 75 mg increments |
mirtazapine (Remeron) 15-45 mg Increase in 15 mg increments |
*adapted from MCPAP For Moms
See PDF at apecguidelines.org for:
Appendix 1: Edinburgh Postnatal Depression Scale (EPDS)
Appendix 2: Columbia-Suicide Severity Rating Scale
Appendix 3: Community Counseling and Therapy Resources
Additional resources for providers and patients:
- Massachusetts Child Psychiatry Access Project (MCPAP) For Moms Provider Toolkit: https://www.mcpapformoms.org/Toolkits/Toolkit.aspx
- Massachusetts Child Psychiatry Access Project (MCPAP) For Moms Provider Contact Number for consultation: 855-Mom-MCPAP (855-666-6272)
- NICHD Moms’ Mental Health Matters:
https://www.nichd.nih.gov/ncmhep/initiatives/moms-mental-health-matters/moms/Pages/default.aspx - Council on Patient Safety in Women’s Healthcare:
http://www.safehealthcareforeverywoman.org/secure/maternal-mental-health.php
References
ACOG Committee Opinion Number 630: Screening for perinatal depression. May 2015.
ACOG Practice Bulletin Number 92: Use of psychiatric medications during pregnancy and lactation. April 2008.
Eke AC, Saccone G, Berghella V. Selective serotonin reuptake inhibitor (SSRI) use during pregnancy and risk of preterm birth: a ystematic review and meta-analysis. BJOG. 2016 Nov;123(12):1900-1907.
Massachusetts Child Psychiatry Access Project (MCPAP) For Moms: https://www.mcpapformoms.org/Default.aspx
Wisner KL, Sit DKY, Hanusa BH, Moses-Kolko EL, Bogen DL, et al .. Major depression and antidepressant treatment: Impact on pregnancy and neonatal outcomes. Am J Psychiatry. 2009 May;166(5):557-566.
Yonkers KA, Wisner KL, Stewart DE, Oberlander TF, Dell DL, Stotland, N, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:703-13. Reaffirmed 2014
- An individual and family mental health history (including any past and current medications) should be included in the intake history
- All women should be screened at least once during pregnancy or postpartum. APEC recommends screening 3 times using the Edinburgh Postnatal Depression Scale (see Appendix 1) at:
The first prenatal visit
24-28 weeks (with the BSST)
Postpartum [high-risk at 2 & 6 weeks; average risk at 6 weeks] - Patients at high-risk for PP depression include those with any prior history of depression or other mental health disorder.
Edinburgh | Postnatal | Depression | Scale | |
EPDS Score | Symptoms | Treatment options | Medication | Additional |
0-9 | Limited/none | Counseling therapy
Community/social support Physical activity |
||
10-13 | Mild | Consider | Counseling therapy
Community/social support Physical activity |
|
14-18 | Moderate | Consider inpatient hospitalization when safety or ability to care for self is a concern | Recommend | Counseling therapy
Community/social support Physical activity |
≥19 | Severe | Consider inpatient hospitalization when safety or ability to care for self is a concern | Initiate | Refer for psychiatry consult in addition to counseling
Counseling therapy Community/social support Physical activity |
General management of depression
A score of > 10 on the EPDS suggests a patient is depressed.
- Always consider comorbid psychiatric conditions (e.g. psychosis & substance use) and medical causes of depression (e.g. thyroid dysfunction)
- Assess best treatment options for individual patient using table above
- If antidepressant is indicated, screen for bipolar disorder prior to prescribing monotherapy SSRI
- Always refer for psychotherapy (Appendix 3: Resources) in addition to medication
Management of suicidal ideation
A positive answer on question #10 of the EPDS suggests the patient is at risk for self-harm or suicide
- Immediately assess further a positive EPDS #10 or any disclosure of suicidal ideation with the Columbia-Suicide Severity Rating Scale (Appendix 2)
- Patients needing additional psychiatric consultation should be immediately evaluated in the Emergency Department or other clinical arena where access to Psychiatric Services are available.
Questions to screen for bipolar disorder (verbally ask these questions prior to starting SSRI monotherapy)
Initial screen:
If yes to questions 1 and/or 2, then continue to screen with question 3:
- Some people have periods lasting several days or longer when they feel much more excited and full of energy than usual. Their minds go too fast. They talk a lot. They are very restless or unable to sit still and they sometimes do things that are unusual for them, such as driving too fast or spending too much money. Have you ever had a period liked this lasting several days or longer?
- Have you ever had a period lasting several days or longer when most of the time you were so irritable or grouchy that you started arguments, shouted at people, or hit people?
- People who have episodes like this often have changes in their thinking and behavior at the same time, like being more talkative, needing very little sleep, being very restless, going on buying sprees, and behaving in ways they would normally think are inappropriate. Did you ever have any of these changes during your episodes of being excited and full of energy/very irritable or grouchy?
If yes to question 3, the patient may have bipolar disorder; refer to psychiatry
If no to question 3, OK to proceed with SSRI monotherapy
Attempt to schedule patient with mental health provider. Use these guidelines if you do not have a mental health provider available or while you are attempting to schedule appointment.
- If patient has a history of taking an antidepressant that helped, prescribe that antidepressant
- If no history of taking an antidepressant, use Zoloft (sertraline) as to date there is the most literature and clinical experience with this SSRI. Alternatives are Prozac (fluoxetine) or Celexa (citalopram).
- Start with half the recommended dose for 2 weeks, then increase to recommended dose as tolerated to minimize side effects (e.g. GI disturbance, dizziness, drowsiness)
- A single medication at a higher dose is favored over multiple medications
- Once treatment is initiated, reevaluate using the EPDS and clinical assessment
If no/minimal clinical improvement after 4-8 weeks:
If patient has no or minimal side effects, increase the dose
If has been on therapeutic dose for ≥ 8 weeks without response, consider switching medication versus increasing doseIf patient has side effects, switch medication
If clinical improvement and no/minimal side effects:
Reevaluate every month and at PP visit
Refer to PCP or community psych provider for ongoing care at PP visit - If an antidepressant has helped during pregnancy, continue it during breastfeeding. Sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox) are considered the safest during lactation as they have the lowest degree of translactal passage and fewest reported adverse effects compared to other anti-depressants. If starting an SSRI postpartum, choose one of these.
First line treatment (SSRIs) Doses are listed as starting dose-max dose
sertraline (Zoloft) 50-200 mg Increase in 50 mg increments |
fluoxetine (Prozac) 20-60 mg Increase in 10 mg increments |
citalopram (Celexa) 20-40 mg Increase in 10 mg increments |
escitalopram (Lexapro) 10-20 mg Increase in 10 mg increments |
Second line treatment
Consider using a second line medicine if it has worked in the past
SSRIS | paroxetine (Paxil) 20-60 mg Increase in 10 mg increments |
fluvoxamine (Luvox) 50-200 mg Increase in 50 mg increments |
SNRIs | venlafaxine (Effexor) 75-300 mg Increase in 75 mg increments |
duloxetine (Cymbalta) 30-60 mg Increase in 20 mg increments |
Other | bupropion (Wellbutrin) 300-450 mg Increase in 75 mg increments |
mirtazapine (Remeron) 15-45 mg Increase in 15 mg increments |