Antidepressant Use in the Postpartum Period: Practical Considerations

Abstract

Treatment in Psychiatry begins with a hypothetical case illustrating a problem in current clinical practice. The authors review current data on prevalence, diagnosis, pathophysiology, and treatment. The article concludes with the authors' treatment recommendations for cases like the one presented.A 30-year-old woman, 6 weeks postpartum, is referred by her obstetrician for possible postpartum depression. The patient noted onset of symptoms 2 days after delivery of her son; describing the onset, she said she felt as if "a curtain descended upon" her. Her symptoms include low mood, tearfulness, decreased sleep and appetite, significant weight loss, and anhedonia. She feels she cannot care for her son properly and has intrusive thoughts that some unspecified harm may come to him. She adamantly denies thoughts of hurting herself or her son but worries constantly that "something bad will happen." At night, she feels restless and frequently checks that the baby is still breathing. Her concentration is poor, and she often does not shower or take care of household duties, but she does care for her son. On examination, the patient appears sad and anxious, with psychomotor retardation. She denies a previous psychiatric history. Her family history is notable for bipolar I disorder in a paternal uncle and a grandfather. She is breastfeeding.A 27-year-old woman with a history of recurrent major depression since age 18 presents for a consultation during her second trimester of pregnancy. The patient has a history of nonresponse to selective serotonin reuptake inhibitors (SSRIs) and has been hospitalized twice for severe depressive episodes. During the second hospitalization, at age 25, she required six ECT treatments. Since that time, she has been maintained with good results on 75 mg daily of nortriptyline. Her treating psychiatrist recommended that she continue taking the nortriptyline during the pregnancy, which she has done. The patient is now seeking consultation and recommendations regarding breastfeeding after delivery.These clinical vignettes demonstrate just a few of the complexities of treating women with mood disorders during the childbearing years. Much attention has been given to the treatment of women with mood disorders during pregnancy. Less, however, has been focused on the treatment of such women during the postpartum period, although many of the clinical issues are the same-including the fact that if the patient is breastfeeding, the treating psychiatrist has two patients to consider, not just one. This review covers the treatment of new-onset and existing mood disorders during the postpartum period; postpartum depression in bipolar disorder; the implications of breastfeeding while taking psychiatric medications; and nonpharmacological interventions. Postpartum Mood DisordersThree types of postpartum mood disorders are described in the literature: postpartum blues, postpartum depression, and postpartum psychosis. Postpartum blues is a relatively common phenomenon occurring in up to 80% of women, generally wit...

Use of Antidepressants to Treat Postpartum Depression, During Breast Feeding

“…Therefore the interaction of the newborn with a depressed mother may have detrimental consequences particularly with regard to cognitive emotional and social development since during this early period of baby's life the capacities for emotional regulation and healthy attachment relationships are developing [1,19,20]. These infants tend to show more regulation difficulties less eye contact fewer vocalizations delayed language development and lower activity level than infants of non-depressed mothers [1].…”

“…These infants tend to show more regulation difficulties less eye contact fewer vocalizations delayed language development and lower activity level than infants of non-depressed mothers [1]. In other words impairment in the mother can lead to impairment in the infant [19]. Therefore rapid attention and treatment are imperative [11].…”

Transtornos psiquiátricos no pós-parto

“…A maioria das medicações é excretada no leite materno e, por questões éticas, não há estudos controlados avaliando a exposição do recém-nascido. Em geral, têm sido verificados poucos riscos e efeitos colaterais nos lactantes expostos a antidepressivos tricíclicos ou inibidores seletivos da recaptação da serotonina (ISRS) 63,64 .…”

Treatment of Attachment Traumas in Postpartum Depression with Intensive Short-Term Dynamic Psychotherapy: Addressing the Self-Critical Personality

“…In summary, no research to date has substantiated the hypothesis that PD is related to hormonal changes. Although few randomized control trials have been conducted, it seems that psychopharmacological treatments can alleviate the symptoms of PD [24]. However, there is no evidence that medications have any lasting effect once they have been discontinued [25].…”