The Treatment of Women with Posatpartum Depression

Results of a MEDLINE Search by Ivan Goldberg, M.D.

J Midwifery Womens Health. 2007 Jan-Feb;52(1):56-62.

The role of exercise in treating postpartum depression: a review of the
literature.

Daley AJ, Macarthur C, Winter H.

Department of Primary Care and General Practice Clinical Sciences Building,
University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. a.daley@bham.ac.uk

There is now evidence to support the antidepressant effects of exercise in
general and in clinical populations. This article reviews the evidence regarding
the potential role of exercise, particularly pram walking, as an adjunctive
treatment for postpartum depression. Database searches revealed two small
randomised controlled trials conducted in Australia which support exercise as a
useful treatment for women with postpartum depression. In addition, uncontrolled
studies and observational evidence suggest that postpartum women, some of whom
were depressed, report benefit from participation in exercise programmes. There
are plausible mechanisms by which exercise could have such an effect. Limited
evidence supports a relationship between participation in exercise and reduction
in postpartum depression. Given the reluctance by some women to use
antidepressant medication postpartum and the limited availability of
psychological therapies, exercise as a therapeutic possibility deserves further
exploration. Further research using well-designed randomised controlled trial
methodologies are warranted.
———-
Can J Psychiatry. 2006 Oct;51(11):704-10.

Demographic characteristics of participants in studies of risk factors,
prevention, and treatment of postpartum depression.

Ross LE, Campbell VL, Dennis CL, Blackmore ER.

Women’s Mental Health and Addiction Research Section, Centre for Addiction and
Mental Health, Toronto, Ontario. l.ross@utoronto.ca

OBJECTIVES: Metaanalyses have found that sociodemographic variables are not
strong predictors of postpartum depression. However, no studies have
systematically examined the extent to which the samples used in published
research on postpartum depression have included sufficiently diverse samples of
women to merit this conclusion. The objectives o this study were to examine the
demographic characteristics of participants in previously published studies and
to document existing gaps in the current literature. METHOD: We extracted age,
ethnicity, relationship status, and socioeconomic status of 51 453 participants
from 143 studies previously selected for systematic literature reviews. RESULTS:
Few studies reported complete demographic data; however, existing data indicate
that participants were predominantly aged 25 to 35 years, white, partnered, and
of mid- or high-socioeconomic status. CONCLUSIONS: To assess the external
validity of the findings, improved reporting of demographic characteristics is
required in publications related to postpartum depression. Additional research
is needed to understand postpartum depression among understudied populations.
———-
Aust Fam Physician. 2006 Sep;35(9):670-3.

Perinatal depression–assessment and management.

Buist A.

Women’s Mental Health, University of Melbourne, Austin Health and Northpark
Private Hospitals, Melbourne, Victoria. a.buist@unimelb.edu.au

BACKGROUND: Depression and anxiety often begin in pregnancy, particularly third
trimester, therefore ‘perinatal’ rather than postnatal depression might be a
better term to describe this disorder. OBJECTIVE: This article outlines an
approach to assessment and management of perinatal depression. DISCUSSION:
Psychological difficulties are common after childbirth and have potentially
serious consequences. Treatment needs to consider the complex interplay of
biology and psychology, and both mother and infant need consideration. Early,
assertive identification and sensitive management, mindful of risks and benefits
to both mother and infant, is the best current approach to improving outcomes.

Publication Types:
Review

PMID: 16969433 [PubMed – indexed for MEDLINE]

4: Arch Womens Ment Health. 2006 Nov;9(6):303-8. Epub 2006 Aug 21.

Patient choice of treatment for postpartum depression: a pilot study.

Pearlstein TB, Zlotnick C, Battle CL, Stuart S, O’Hara MW, Price AB, Grause MA,
Howard M.

Department of Psychiatry and Human Behavior, Brown Medical School, Providence,
RI 02905, USA. teri_pearlstein@brown.edu

OBJECTIVE: The lack of systematic efficacy research makes the selection of
optimal treatment for postpartum depression (PPD) difficult. Moreover, the
treatment decisions for women with PPD who are breastfeeding are heavily
influenced by their concerns about infant exposure to antidepressant medication.
The objective of this pilot trial was to examine the clinical characteristics of
women with PPD associated with treatment selection. METHOD: This open pilot
trial offered 23 women with PPD one of 3 treatment options: sertraline,
interpersonal psychotherapy (IPT), or their combination administered in an
outpatient mental health setting over 12 weeks. Baseline and treatment outcome
measures included the Hamilton Rating Scale for Depression (HRSD), the Beck
Depression Inventory (BDI) and the Edinburgh Postnatal Depression Scale (EPDS).
RESULTS: Completers across all 3 treatment groups (n = 18) experienced
significant clinical improvement with each of the 3 treatment modalities on the
HRSD (p < 0.001), BDI (p < 0.001) and EPDS (p < 0.001). There were trends for
women with a prior depression to more frequently choose sertraline as a
treatment (alone or with IPT, p = 0.07), and for women who were breastfeeding to
choose sertraline (alone or with IPT, p = 0.10) less frequently. CONCLUSION: In
this small sample of women with PPD, most women chose IPT with or without
sertraline. A larger randomized study could further confirm the suggested
predictors of treatment selection identified in this study: previous depression
and breastfeeding status.
———-
Prostaglandins Leukot Essent Fatty Acids. 2006 Oct-Nov;75(4-5):291-7. Epub
2006 Aug 22.

Omega-3 fatty acids and perinatal depression: a review of the literature and
recommendations for future research.

Freeman MP.

Women’s Mental Health Program, Department of Psychiatry, University of Arizona
College of Medicine, Tucson, AZ 85724-5002, USA. marlenef@email.arizona.edu

INTRODUCTION: Perinatal depression refers to major depression in the context of
pregnancy and postpartum. In consideration of its prevalence and consequences,
the treatment and prevention of perinatal depression should be important public
health priorities. Omega-3 fatty acids are attractive for consideration in
perinatal women, due to known health benefits for the mother and baby.
Antidepressant medications may pose risks in utero and in breastfeeding.
METHODS: MEDLINE and manual searches were conducted. RESULTS: Epidemiological
and preclinical data support a role of omega-3 fatty acids in perinatal
depression. Two studies failed to support a role of omega-3 fatty acids for
postpartum depression prophylaxis, although one included a small sample, and the
other utilized a low dosage. Two pilot studies suggest good tolerability and
potential efficacy in the acute treatment of perinatal depression. CONCLUSIONS:
Further research studies are warranted to determine the role of omega-3 fatty
acids in the treatment of perinatal depression.
———-
Bipolar Disord. 2006 Aug;8(4):411-4.

A cautionary note on the use of antidepressants in postpartum depression.

Sharma V.

Department of Psychiatry and Obstetrics & Gynecology, University of Western
Ontario and Mood Disorders Program, Regional Mental Health Care London, ON,
Canada. vsharma@uwo.ca

OBJECTIVES: This paper discusses the effect of antidepressant use on the illness
course in three women who were treated for first-onset postpartum depression
(PPD) following childbirth. METHODS: A report of three cases of early-onset PPD
in which bipolarity manifested following antidepressant treatment. RESULTS:
There was no past history of psychiatric disturbance but in each case there was
a family history of bipolar (BP) disorder. Treatment with antidepressants
resulted in a highly unstable illness course characterized by a mixed episode,
cycle acceleration, and a postpartum psychosis. However, discontinuation of
antidepressants and institution of treatment with mood stabilizers and atypical
neuroleptics resulted in sustained improvement and symptom remission.
CONCLUSIONS: Caution is urged in the use of antidepressants to treat early-onset
PPD in women at risk for developing BP disorder due to a family history of
bipolar illness.
———-
J Clin Psychopharmacol. 2006 Aug;26(4):353-60.

Postpartum depression: a randomized trial of sertraline versus nortriptyline.

Wisner KL, Hanusa BH, Perel JM, Peindl KS, Piontek CM, Sit DK, Findling RL,
Moses-Kolko EL.

Department of Obstetrics and Gynecology and Reproductive Sciences, Epidemiology
and Women’s Studies, Western Psychiatric Institute and Clinic/University of
Pittsburgh Medical Center, 3811 O’Hara Street, Pittsburgh, PA 15213, USA.
WisnerKL@upmc.edu

Symptom reduction and improvement in functioning in women with postpartum major
depression treated with a tricyclic antidepressant versus a serotonin reuptake
inhibitor were compared. The design was a double-blind, 8-week comparative trial
of nortriptyline (NTP) versus sertraline (SERT) with a 16-week continuation
phase. Women aged 18 to 45 years with postpartum major depression and a 17-item
Hamilton Rating Scale for Depression score of 18 or more were eligible. Subjects
were randomized to NTP or SERT and treated with a fixed-dosing strategy. Of 420
women interviewed, 109 eligible women received medication, and 95 provided
follow-up data. The proportion of women who responded and remitted did not
differ between drugs at 4, 8, or 24 weeks. Times to response and remission also
did not differ. Psychosocial functioning improved similarly in both drug-treated
groups of mothers. The total side effect burden of each drug was similar,
although side effect profiles differed between agents. No clinical or
demographic variables differentiated responders by drug. Women who were
responders and remitters at week 8 could be identified earlier if they were
treated with SERT than with NTP. Breast-fed infant serum levels were near or
below the level of quantifiability for both agents.
———-
Bipolar Disord. 2006 Jun;8(3):207-20.

Prophylactic treatment of bipolar disorder in pregnancy and breastfeeding: focus
on emerging mood stabilizers.

Gentile S.

Department of Mental Health ASL Salerno 1, Operative Unit District n 4, Salerno,
Italy. salvatore_gentile@alice.it

OBJECTIVES: Bipolar disorders are reported to have a high incidence during
childbearing years and the need may arise to start or continue a pharmacological
treatment during pregnancy and the postpartum period. In the last few years
several investigations have evaluated the efficacy of emerging mood-stabilizing
agents in the treatment of bipolar disorders, such as lamotrigine, olanzapine,
risperidone, quetiapine, aripiprazole and ziprasidone. A number of studies,
which examined the use of oxcarbazepine, point to its potential usefulness in
prophylactic treatment. The aim of this review is to compare information from
the literature on the safety of lamotrigine, oxcarbazepine, risperidone,
olanzapine, and quetiapine to the safety data on classic mood stabilizers during
pregnancy and the postpartum period. METHODS: A computerized search carried out
from 1980 to April 5, 2006 led to the summarization of the results. (References
were updated after acceptance and prior to publication.) RESULTS: Emerging mood
stabilizers show uncertain safety parameters in pregnancy and lactation. Limited
information on lamotrigine and oxcarbazepine does not suggest a clear increase
in teratogenicity, while olanzapine appears to be associated with a higher risk
of metabolic complications in pregnant women. Data about risperidone and
quetiapine are still inconclusive. Finally, the literature on the safety of
these compounds in breastfeeding is anecdotal. CONCLUSIONS: Untreated pregnant
bipolar women are at an increased risk of poor obstetrical outcomes and relapse
of affective symptoms. On the other hand, classic antiepileptic drugs are
well-known human teratogens, whereas data on lithium are partially ambiguous.
The safety of emerging mood stabilizers in pregnancy and breastfeeding has not
been examined extensively. Therefore, when approaching bipolar disorder, if
possible, each episode must be considered separately.
———-
J Adv Nurs. 2006 May;54(4):450-6.

Being reborn: the recovery process of postpartum depression in Taiwanese women.

Chen CH, Wang SY, Chung UL, Tseng YF, Chou FH.

College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan.
chunghey@kmu.edu.tw

AIM: This paper reports a qualitative study describing the process of recovery
from postpartum depression in Taiwanese women. METHODS: We carried out a study
using grounded theory with a purposive sample of 23 postnatally depressed women
in 2001-2002. The Beck Depression Inventory was used to screen for severe
depression. Women with scores higher than 16 at 6 weeks after childbirth were
categorized as having postpartum depression. Only two out of the 23 mothers were
being treated for depression at the time. The data were analysed by constant
comparative method. FINDINGS: ‘Being reborn’ was the core concept that emerged
from the data on the mothers’ experience of going through postnatal depression,
which was a process of descent into near-death insanity and eventual rebirth.
Such postnatally depressed mothers often underwent four stages of coping with
the loss of self or loss of former identity and attachment to their new lives as
mothers. The four stages were: (1) shattered role identity, (2) feeling trapped
and breaking down, (3) struggling for self-integrity and (4) regaining vitality.
CONCLUSION: The experience of postpartum depression should be examined within
the social and cultural contexts in which it occurs. These Taiwanese data can be
used to develop culturally-sensitive health care. The nursing role is primarily
that of reflective listening to help the women adjust to the process of being
reborn–an internal process of painful growth represented by motherhood and
striving to protect the real self in order to maintain emotional health while
negotiating a developmental transition. Preventive interventions might include
providing guidance for parenting, counselling of individual mothers, and
facilitating the development of support groups.
———-
Nurs Res. 2006 Mar-Apr;55(2 Suppl):S23-7.

Postpartum depression treatment rates for at-risk women.

Horowitz JA, Cousins A.

William F. Connell School of Nursing, Boston College, 140 Commonwealth Avenue,
Chestnut Hill, MA 02467, USA. horowitz@bc.edu

BACKGROUND: Despite growing awareness of postpartum depression (PPD), screening
is not yet standard care and evidence that screening produces improved health
outcomes remains limited. OBJECTIVES: To examine mental health treatment rates
at 3 and 4 months postpartum for women who were identified with PPD symptoms at
2 to 4 weeks after delivery. METHODS: A secondary analysis of data from a
mother-infant intervention study for women with PPD symptoms was conducted.
Postpartum women were screened for PPD symptoms; women with positive PPD screens
were assessed at 2, 3, and 4 months postpartum. Research nurses monitored
symptoms and encouraged and assisted women who experienced moderate to severe
PPD symptoms to seek evaluation and mental health referral from their primary
care providers. RESULTS: From the screening of a community-based population of
1,215 postpartum women, 122 women identified as having PPD enrolled in the
clinical trial and 117 participated in all assessments. At 3 and 4 months
postpartum, only 14 women (12%) received psychotherapy and fewer received
psychopharmacologic treatment. In comparison to women with low PPD symptoms,
significantly more women with high PPD symptoms were in therapy at 3 and 4
months. DISCUSSION: The inadequacy of treatment rates among a sample of at-risk
women raises grave concern. Possible barriers to referral and treatment include
clinician and healthcare system, third-party payment, and personal factors.
Evaluating health outcomes from PPD screening and testing approaches designed to
increase treatment participation are warranted.
———-
Am J Orthopsychiatry. 2006 Jan;76(1):115-9.

The impact of treatment intervention on parenting stress in postpartum depressed
mothers: a prospective study.

Misri S, Reebye P, Milis L, Shah S.

BC Women’s Hospital, Reproductive Mental Health Program, Vancouver, BC, Canada.
smisri@providencehealth.bc.ca

The aim of this study was to evaluate whether treatment intervention for
postpartum depression impacted maternal parenting stress levels. Twenty-three
mothers referred for postpartum mood and anxiety disorder to an outpatient
program were included in the study. Statistically and clinically significant
decreases in levels of parenting stress were evident at the end of the
treatment. Subjects’ perceptions of their parenting characteristics were found
to be a major contributor to stress levels. In addition to monitoring of
depressive symptoms, routine assessment of maternal parenting qualities is
recommended to ensure healthy child outcomes.
———-
J Psychosoc Nurs Ment Health Serv. 2006 Jan;44(1):37-45.

Telecare for women with postpartum depression.

Ugarriza DN, Schmidt L.

University of Miami School of Nursing, Coral Gables, Florida 33143, USA.
dugarriza@miami.edu

Data were collected to pilot test the feasibility and effects of telecare as an
intervention for depression in a small group of mothers with postpartum
depression. Treatment involved a 10-week telecare therapy consisting of three
related aspects: cognitive-behavioral therapy, relaxation techniques, and
problem-solving strategies. Beck Depression Inventory II scores were
significantly lower after telecare treatment. Women identified psycho-education
as the greatest help to them.
———-
Nurs Times. 2006 Jan 3-9;102(1):24-6.

The assessment and treatment of postnatal depression.

Hanley J.

University of Wales, Swansea.

Postnatal depression is a common depressive illness with a variety of potential
causes. This article outlines the detection of postnatal depression, the effects
that the condition has on the whole family and treatment options.
———-
Acta Psychiatr Scand. 2006 Jan;113(1):31-5.

Randomized dose-ranging pilot trial of omega-3 fatty acids for postpartum
depression.

Freeman MP, Hibbeln JR, Wisner KL, Brumbach BH, Watchman M, Gelenberg AJ.

Department of Psychiatry, University of Arizona College of Medicine, Tucson, AZ
85724-5002, USA. marlenef@email.arizona.edu

OBJECTIVE: Postpartum depression (PPD) affects 10-15% of mothers. Omega-3 fatty
acids are an intriguing potential treatment for PPD. METHOD: The efficacy of
omega-3 fatty acids for PPD was assessed in an 8-week dose-ranging trial.
Subjects were randomized to 0.5 g/day (n = 6), 1.4 g/day (n = 3), or 2.8 g/day
(n = 7). RESULTS: Across groups, pretreatment Edinburgh Postnatal Depression
Scale (EPDS) and Hamilton Rating Scale for Depression (HRSD) mean scores were
18.1 and 19.1 respectively; post-treatment mean scores were 9.3 and 10.0.
Percent decreases on the EPDS and HRSD were 51.5% and 48.8%, respectively;
changes from baseline were significant within each group and when combining
groups. Groups did not significantly differ in pre- or post-test scores, or
change in scores. The treatment was well tolerated. CONCLUSION: This study was
limited by small sample size and lack of placebo group. However, these results
support further study of omega-3 fatty acids as a treatment for PPD.
———-
Br J Clin Psychol. 2005 Nov;44(Pt 4):529-42.

Comment in:
Evid Based Ment Health. 2006 May;9(2):50.

A randomized controlled trial of psychological interventions for postnatal
depression.

Milgrom J, Negri LM, Gemmill AW, McNeil M, Martin PR.

Department of Psychology, School of Behavioural Science, University of
Melbourne, Australia. jeannette.milgrom@austin.org.au

OBJECTIVES: First, to establish the efficacy of psychological interventions
versus routine primary care for the management of postnatal depression (PND).
Secondly, to provide a direct comparison of cognitive-behavioural therapy (CBT)
versus counselling and, finally, to compare the relative value of group and
individual delivery formats. DESIGN: The study involved 192 depressed women
drawn from a large community screening programme in Melbourne, Australia and
allocated to cognitive behaviour therapy, counselling, or routine primary care.
Baseline and post-intervention measures of depression and anxiety were collected
in the form of validated self-report inventories. METHOD: Women were screened in
the community and diagnosis of depression confirmed with a standardized
psychiatric interview. Interventions were of 12 weeks duration, including three
partner sessions, and adhered to a structured manual. RESULTS: Psychological
intervention per se was superior to routine care in terms of reductions in both
depression and anxiety following intervention. CONCLUSIONS: For those women with
PND, psychological intervention is a better option than routine care, leading to
clinically significant reduction of symptoms. Counselling may be as effective as
group cognitive behaviour therapy. The benefits of psychological intervention
may be maximized by being delivered on a one-to-one basis.
———-
CNS Spectr. 2005 Dec;10(12):944-52.

The role of estrogen therapy in postpartum psychiatric disorders: an update.

Gentile S.

Mental Health Center, Azienda Sanitaria Locale Salerno Number 1, Nocera
Inferiore, Italy. salvatore_gentile@aliceposta.it

OBJECTIVES: The aim of this review is to assess and summarize the existing
literature data about the efficacy of estrogen replacement therapy (ERT) in
preventing and treating postpartum psychiatric disorders. METHODS: An extensive
and unrestrictive computerized search (from 1970 to June 2005) on
MEDLINE/PubMed, TOXNET, EMBASE, and Cochrane Databases was conducted with the
following search terms: estradiol, estrogen-treatment, hormonal treatment,
therapy, postpartum depression, postnatal depression, puerperal depression,
postpartum blues, postpartum psychosis, lactation, and breastfeeding. RESULTS:
In assessing available literature information about the role of ERT in
preventing and treating puerperal psychiatric diseases, all reviewed studies
were found to suffer from severe methodological limitations. CONCLUSION:
Well-designed and strictly focused multicenter trials are warranted in order to
firmly establish the effectiveness of ERT in puerperal psychiatric disorders.
———-
Prev Med. 2006 Jan;42(1):4-13. Epub 2005 Dec 7.

Omega-3 polyunsaturated fatty acids and depression: a review of the evidence and
a methodological critique.

Sontrop J, Campbell MK.

Department of Epidemiology and Biostatistics, Kresge Bldg., K201, The University
of Western Ontario, London, Ontario, Canada N6A 5C1. jsontrop@uwo.ca

Several lines of evidence indicate an association between omega-3
polyunsaturated fatty acids (PUFAs) and depression. The purpose of this review
was to evaluate the evidence to date within the context of the study design and
methodology used. In case-control and cohort studies, concentrations of omega-3
PUFAs were lower in participants with unipolar and postpartum depression. Fish
are the major dietary source of omega-3 PUFAs, and infrequent fish consumption
is associated with depression in epidemiological studies. While these findings
do not appear to be the result of confounding, in some studies failure to detect
confounding may be due to a lack of power or incomplete control. In four of
seven double-blind randomized controlled trials, depression was significantly
improved upon treatment with at least 1 g/day of eicosapentaenoic acid, an
omega-3 PUFA. While clinical significance was demonstrated, preservation of
blinding may be a limitation in this area of research. It remains unclear
whether omega-3 supplementation is effective independently of antidepressant
treatment, for depressed patients in general or only those with abnormally low
concentrations of these PUFAs. The relationship between omega-3 PUFAs and
depression is biologically plausible and is consistent across study designs,
study groups, and diverse populations, which increases the likelihood of a
causal relationship.
———-
Arch Womens Ment Health. 2006 Jan;9(1):31-9. Epub 2005 Oct 12.

Erratum in:
Arch Womens Ment Health. 2006 Mar;9(2):115. Kumar, R [added].

Group interpersonal psychotherapy for postnatal depression: a pilot study.

Reay R, Fisher Y, Robertson M, Adams E, Owen C, Kumar R.

Academic Unit of Psychological Medicine, ANU Medical School, The Canberra
Hospital, Garran, Australia. Rebecca.Reay@act.gov.au

We conducted a pilot study to assess the potential effectiveness of group
interpersonal psychotherapy (IPT-G) as a treatment for postnatal depression
(PND). The study was also established to test a treatment manual for IPT-G,
assess the acceptability of this format for participants and test a recruitment
strategy for a randomised controlled trial. 18 mothers diagnosed with PND
participated in 2 individual session and 8 sessions of group IPT. A two-hour
psychoeducational session was also held for the partners of the participants.
Measures of depressive symptomatology and social adjustment were administered by
an independent clinician at baseline, 4 weeks, 8 weeks and 3 months post
treatment. Patient satisfaction with the treatment was also evaluated. Severity
scores on the BDI, EPDS and the HDRS decreased from pre- to post-treatment. This
was maintained at three months follow up. No overall improvement in the Social
Adjustment Scale-Self Report was noted, although there was improvement in their
relationship with their significant other. The results confirm previous work
that IPT-G may improve symptom severity for women suffering from postnatal
depression. Limitations included the use of antidepressant therapy by 67% of
subjects and the lack of a control group. There is a need for further randomised
controlled trials of IPT-G with larger sample sizes to establish its
effectiveness as treatment for PND.
———-
Expert Opin Pharmacother. 2005 Oct;6(12):1999-2005.

Pharmacotherapy of postpartum depression: current practice and future
directions.

Tcheremissine OV, Lieving LM.

Department of Psychiatry and Behavioural Science, University of Texas Health
Science Center, 1300 Moursund Street, Houston, TX 77030-3497, USA.
Oleg.V.Tcheremissine@uth.tmc.edu

Postpartum depression has well-documented consequences for the mother, child,
family and society as a whole. Despite an increasing awareness of postpartum
depression, it often remains unrecognised by clinicians and poorly understood by
researchers. The current trend is undoubtedly a result of the complex nature of
depressive disorders accentuated by difficulties with the current classification
schemas. Systematic prospective data on the onset of depression during pregnancy
and the postpartum period, as well as on the risk of relapse during these
periods in women with previous histories of mood and anxiety disorders, are
limited. This article reviews clinically relevant outcomes and current trends in
the pharmacotherapy of postpartum depression from selected clinical trials.
Critical issues of the neurobiology and phenomenology of postpartum depression
are raised, and future directions of the pharmacological treatments of
postpartum depression are examined.
———-
J Psychiatr Pract. 2001 May;7(3):185-208.

Treatment of depression in women: a summary of the expert consensus guidelines.

Altshuler LL, Cohen LS, Moline ML, Kahn DA, Carpenter D, Docherty JP, Ross RW.

UCLA Neuropsychiatric Institute and VA Greater Los Angeles Healthcare Systems,
USA.

Women constitute two-thirds of patients suffering from common depressive
disorders, making the treatment of depression in women a substantial public
health concern. However, high-quality, empirical data on depressive disorders
specific to women are limited, and there are no comprehensive evidence-based
practice guidelines on the best treatments for these illnesses. To bridge the
gap between research evidence and key clinical decisions, the authors developed
a survey of expert opinion concerning treatment of four depressive conditions
specific to women: premenstrual dysphoric disorder, depression in pregnancy,
postpartum depression in a mother choosing to breast-feed, and depression
related to perimenopause/menopause. The survey asked about 858 treatment options
in 117 clinical situations and included a broad range of pharmacological,
psychosocial, and alternative medicine approaches. The survey was sent to 40
national experts on women’s mental health issues, 36 (90%) of whom completed it.
The options, scored using a modified version of the RAND Corporation’s 9-point
scale for rating appropriateness of medical decisions, were assigned one of
three categorical rankings-first line/preferred choice, second line/alternate
choice, third line/usually inappropriate-based on the 95% confidence interval of
each item’s mean rating. The expert panel reached consensus (defined as a
non-random distribution of scores by chi-square “goodness-of-fit” test) on 76%
of the options, with greater consensus in situations involving severe symptoms.
Guideline tables indicating preferred treatment strategies were then developed
for key clinical situations.The authors summarize the expert consensus
methodology they used and then, for each of the four key areas, review the
treatment literature and summarize the experts’ recommendations and how they
relate to the research findings. For women with severe symptoms in each area we
asked about, the first-line recommendation was antidepressant medication
combined with other modalities (generally psychotherapy). These recommendations
parallel existing guidelines for severe depression in general populations. For
initial treatment of milder symptoms in each situation, the panel was less
uniform in recommending antidepressants, and either gave equal endorsement to
other treatment modalities (e.g., nutritional or psychobehavioral approaches in
PMDD; hormone replacement in perimenopause) or preferred psychotherapy over
medication (during conception, pregnancy, or lactation). In all milder cases,
however, antidepressants were recommended as at least second-line options. Among
antidepressants, selective serotonin reuptake inhibitors (SSRIs) were
recommended as first-line treatment in all situations. The specific SSRIs that
were preferred depended on the particular clinical situation. Tricyclic
antidepressants were highly rated alternatives to SSRIs in pregnancy and
lactation.In evaluating many of the treatment options, the experts had to
extrapolate beyond controlled data in comparing treatment options with each
other or in combination. Within the limits of expert opinion and with the
expectation that future research data will take precedence, these guidelines
provide some direction for addressing common clinical dilemmas in women, and can
be used to inform clinicians and educate patients regarding the relative merits
of a variety of interventions.
———-
Am J Obstet Gynecol. 2005 May;192(5):1446-8.

Early intervention for perinatal depression.

Thoppil J, Riutcel TL, Nalesnik SW.

Obstetrics and Gynecology, Wilford Hall Medical Center, Lackland Air Force Base,
San Antonio, Tex 78236, USA. thoppil@mailblocks.com

OBJECTIVE: This study was undertaken to design a process that effectively
identifies and facilitates early intervention for women in an obstetrics clinic
who are at risk for postpartum depression. STUDY DESIGN: Under this new program,
labeled ISIS (Identify, Screen, Intervene, Support), we educated our new
obstetric patients and clinic staff about postpartum depression through patient
education classes, departmental lectures, and handouts. Then, we implemented
simple procedures to identify risk factors for depression at intake and screened
for depressive symptoms at the 32-week visit using the Edinburgh Postnatal
Depression Scale (EPDS). In addition, we facilitated treatment of at-risk or
symptomatic patients with the introduction of a social work consultant in the
clinic setting. RESULTS: In an obstetric chart review, 75% of our patients were
screened for depression in pregnancy. Ten percent of these women demonstrated
symptoms of depression warranting further evaluation. CONCLUSION: Preliminary
data from our multidisciplinary approach suggest that educating, screening, and
appropriately treating or referring these women can take place in a busy
obstetric clinic.
———-
Pharmacotherapy. 2005 Mar;25(3):411-25.

The use of tricyclic antidepressants and selective serotonin reuptake inhibitors
in women who are breastfeeding.

Whitby DH, Smith KM.

Department of Pharmacy Services, Shands Hospital at the University of Florida,
Gainesville, Florida, USA.

Postpartum depression is a well-recognized psychiatric condition that has gained
increased attention over the past decade due to several nationally publicized
tragedies. Medical management of this condition in women who are breastfeeding
provides a unique challenge to health care professionals who may seek to
maintain a fine balance between limiting the infant’s exposure to
hormone-altering drugs and maintaining the benefits of breastfeeding. No
controlled trials have examined antidepressant therapy in nursing women;
however, numerous case reports and case series have been published. Relatively
few serious adverse effects have been reported. Although tricyclic
antidepressants have been the treatment of choice in the past, selective
serotonin reuptake inhibitors are gaining popularity due to their superior
safety profiles. Of all the agents reviewed in the literature, sertraline was
the most prescribed, and no adverse effects were reported. Therefore, this agent
would be a good first choice for treatment-naive women. For treatment of
postpartum depression in women with a history of successfully treated
depression, the most practical approach may be to continue therapy with the
previously effective agent. Treatment should be maintained at the lowest
effective dosage to minimize infant exposure. Both mother and child should be
closely monitored; in addition, collaboration between the prescribing physician
and the child’s pediatrician is essential.
———-
Int J Neuropsychopharmacol. 2005 Sep;8(3):445-9. Epub 2005 Apr 7.

Bupropion SR for the treatment of postpartum depression: a pilot study.

Nonacs RM, Soares CN, Viguera AC, Pearson K, Poitras JR, Cohen LS.

Perinatal and Reproductive Psychiatry Clinical Research Program, Massachusetts
General Hospital (MGH), Boston, 02114, USA. RNONACS@PARTNERS.ORG

Despite the prevalence of postpartum depression, few studies have assessed the
efficacy of antidepressants for the treatment of this disorder. Failure to treat
postpartum depression (PPD) places the woman at risk for chronic depression and
may have adverse effects on child wellbeing and development. Eight female
outpatients aged 18-45 yr were enrolled in an 8-wk open-label trial of bupropion
SR for PPD. All patients met DSM-IV criteria for major depression with onset
within 3 months of delivery and scored 17 or greater on the Hamilton Depression
Rating Scale (HAMD) at baseline. Those with onset of depressive symptoms during
pregnancy, psychotic symptoms, or significant medical illness were excluded.
Median scores on the HAMD declined from 20.5 (range 15-38) at baseline to 10.0
(range 1-20) at end-point (p<0.05, Wilcoxon signed-ranks test; LOCF). Six out of
the eight subjects demonstrated a > or =50% decrease in HAMD scores from
baseline; three subjects achieved remission (HAMD score of < or =7) at week 8.
Median final dosage of bupropion SR was 262.5 (range 37.5-300). Bupropion SR was
well tolerated, and no subjects discontinued treatment as a result of medication
side-effects. Bupropion SR represents an effective and well-tolerated
antidepressant for the treatment of PPD.
———-
J Obstet Gynecol Neonatal Nurs. 2005 Mar-Apr;34(2):264-73.

Identifying and treating postpartum depression.

Horowitz JA, Goodman JH.

Massachusetts General Institute of Health, 36 1st Avenue, Boston, MA 02129, USA.

Postpartum depression affects 10% to 20% of women in the United States and
negatively influences maternal, infant, and family health. Assessment of risk
factors and depression symptoms is needed to identify women at risk for
postpartum depression for early referral and treatment. Individual and group
psychotherapy have demonstrated efficacy as treatments, and some
complementary/alternative therapies show promise. Treatment considerations
include severity of depression, whether a mother is breastfeeding, and mother’s
preference. Nurses who work with childbearing women can advise depressed mothers
regarding treatment options, make appropriate recommendations, provide timely
and accessible referrals, and encourage engagement in treatment.
———-
Aust N Z J Psychiatry. 2005 Apr;39(4):274-80.

Role of omega-3 fatty acids as a treatment for depression in the perinatal
period.

Rees AM, Austin MP, Parker G.

School of Psychiatry, University of New South Wales, Black Dog Institute,
Hospital Road, Prince of Wales Hospital, Randwick, NSW 2031, Australia.
a.rees@unsw.edu.au

OBJECTIVES: To consider the possible rationale and utility of omega-3 fatty
acids as a treatment for depression in the perinatal period. METHOD: A review of
published and unpublished research was undertaken, using electronic databases,
conferences proceedings and expert informants. RESULTS: Relevant bodies of
evidence include an epidemiological link between low fish intake and depression.
Laboratory studies show correlations between low omega-3 fatty acid levels and
depression, as well as reduced levels of omega-3 in non-depressed women during
the perinatal period. Treatment studies using omega-3 in patients with mood
disorders further support an omega-3 contribution, as do neuroscientific
theories. Research into omega-3 and infant development also highlights potential
effects of depletion in the perinatal period and supports infant safety and
benefits of supplementation. CONCLUSIONS: There is a relative lack of knowledge
about the safety of standard antidepressants in the perinatal period. There is a
clear need for more research into alternative treatments, such as omega-3 fatty
acids, in the management of depression in the perinatal period.
———-
J Psychosom Obstet Gynaecol. 2004 Sep-Dec;25(3-4):221-33.

Women’s views of antidepressants in the treatment of postnatal depression.

Boath E, Bradley E, Henshaw C.

Faculty of Health and Sciences, Staffordshire University, UK.

Little research has been carried out on the treatment of postnatal depression
and clinicians must currently rely on general recommendations for the use of
antidepressants. Antidepressant medication as the main treatment for depression
in general practice has been shown to be effective when used as prescribed.
However, research has shown that depressed patients consistently receive either
no medication or consistently low doses of medication. This study will
investigate women’s experiences of taking antidepressant medication for
postnatal depression. Thirty-five women with a clinical diagnosis of postnatal
depression who had been prescribed antidepressant medication completed a
questionnaire detailing their experiences of taking medication. Four open-ended
questions and responses were discussed with the women. Of the 35 women who were
prescribed medication, 4 chose not to take it because they were breast-feeding.
Twenty of the women described finding medication helpful. Although only 4 women
directly reported not taking antidepressants as prescribed, the comments made by
a further 9 women suggest that compliance may have been poor. This study
suggests a need to improve information about medication for postnatal
depression. If this information is not provided, women are likely to continue to
self-manage medication at a dosage that may be clinically ineffective.
———-
WMJ. 2004;103(6):56-63.

Postpartum depression: identification, screening, and treatment.

Perfetti J, Clark R, Fillmore CM.

University of Wisconsin Medical School, Madison, 53719, USA.

Depression during the postpartum period is a significant public health concern,
affecting 8%-15% of women and resulting in considerable morbidity for women, and
their infants and families. Risk, prevalence, and distinguishing features of
postpartum mood disorders are provided. Anxiety and depression frequently
co-occur, suggesting symptoms of anxiety should also be attended to when
screening for postpartum depression. Recommendations include the use of a brief,
valid screening instrument as a routine clinical practice and the unique role of
the obstetrician/gynecologist, pediatrician, and family practice physician in
identification and referral. A summary of evidence-based treatment options for
postpartum depression, along with current information about psychotropic
medication, is provided to assist in risk-benefit analyses and decision making
with patients.
———-
J Clin Psychiatry. 2004 Sep;65(9):1252-65.

Treatment of postpartum depression, part 2: a critical review of nonbiological
interventions.

Dennis CL.

University of Toronto, Toronto, Ontario, Canada. cindylee.dennis@utoronto.ca

BACKGROUND: While postpartum depression is a common mental condition with
significant burden, it often remains undiagnosed and untreated. The objective of
this article is to critically review the literature to determine the current
state of scientific knowledge related to the treatment of postpartum depression
from a nonbiological perspective. DATA SOURCES: Databases searched for this
review included MEDLINE, PubMed, CINAHL, PsycINFO, EMBASE, ProQuest, the
Cochrane Library, and the WHO Reproductive Health Library from 1966 to 2003. The
search terms used were postpartum/postnatal depression and randomized
controlled/clinical trials. Published peer-reviewed articles in English from
1990 to 2003 were included in the review, although select earlier studies were
also included based on good methodological quality and/or the absence of more
recent work. METHOD: The criteria used to evaluate the interventions were based
on the standardized methodology developed by the U.S. Preventive Services Task
Force and the Canadian Task Force on Preventive Health Care. RESULTS: Twenty-one
studies that met inclusion criteria were examined. These studies included
interpersonal psychotherapy, cognitive-behavioral therapy, peer and partner
support, nondirective counseling, relaxation/massage therapy, infant sleep
interventions, infant-mother relationship therapy, and maternal exercise.
Although some of these interventions have been better studied for depression
unrelated to childbirth, methodological limitations render their efficacy
equivocal for postpartum depression. CONCLUSIONS: Definite conclusions cannot be
reached about the relative effectiveness of most of the nonbiological treatment
approaches due to the lack of well-designed investigations. Randomized
controlled trials are needed to compare different treatment modalities, examine
the effectiveness of individual treatment components, and determine which
treatments are most useful for women with different risk factors or clinical
presentations of postpartum depression.
———-
J Clin Psychiatry. 2004 Sep;65(9):1242-51.

Treatment of postpartum depression, part 1: a critical review of biological
interventions.

Dennis CL, Stewart DE.

University of Toronto, Toronto, Ontario, Canada. cindylee.dennis@utoronto.ca

BACKGROUND: While postpartum depression is a major health issue for many women
from diverse cultures, this affective condition often remains undiagnosed and
untreated. The objective of this article is to critically review the literature
to determine the current state of scientific knowledge related to the treatment
of postpartum depression from a biological perspective. METHOD: Databases
searched for this review included MEDLINE, PubMed, CINAHL, PsycINFO, EMBASE,
ProQuest, the Cochrane Library, and the WHO Reproductive Health Library from
1966 to 2003. The search terms used were postpartum/ postnatal depression and
randomized controlled/ clinical trials in various combinations. Published
peer-reviewed articles in English from 1990 to 2003 were chosen for review,
although select earlier studies were also included based on good methodological
quality and/or the absence of more recent work. The criteria used to evaluate
the interventions were based on the standardized methodology developed by the
U.S. Preventive Services Task Force and the Canadian Task Force on Preventive
Health Care. RESULTS: Nine studies that met study criteria were examined. The
interventions studied included antidepressant medication, estrogen therapy,
critically timed sleep deprivation, and bright light therapy. Although some of
these interventions have been better studied for depression unrelated to
childbirth, methodological limitations render their efficacy equivocal for
postpartum depression with limited strong evidence available to guide practice
or policy recommendations. CONCLUSIONS: Despite the recent upsurge of interest
in this area, many questions remain unanswered, resulting in diverse research
implications. In view of the lack of randomized controlled trials, psychiatrists
who are experts in the treatment of postpartum mood disorders have developed
consensus guidelines. These guidelines will require regular updating as better
and stronger evidence emerges.
———-
J Clin Psychiatry. 2004 Sep;65(9):1236-41.

Comment in:
J Clin Psychiatry. 2005 Nov;66(11):1494-5; author reply 1495.

The use of paroxetine and cognitive-behavioral therapy in postpartum depression
and anxiety: a randomized controlled trial.

Misri S, Reebye P, Corral M, Milis L.

Department of , Faculty of Medicine, University of British Columbia and
Reproductive Mental Health Programs, St. Paul’s Hospital, Vancouver, British
Columbia, Canada. smisri@providencehealth.bc.ca

BACKGROUND: Approximately 10% to 16% of women experience a major depressive
episode after childbirth. A significant proportion of these women also suffer
from comorbid anxiety disorders. The purpose of this study was to evaluate
whether the addition of cognitive-behavioral therapy (CBT) to standard
antidepressant therapy offers additional benefits in the treatment of
post-partum depression with comorbid anxiety disorders. METHOD: Thirty-five
women referred to a tertiary care hospital outpatient program with a DSM-IV
diagnosis of postpartum depression with comorbid anxiety disorder were randomly
assigned to 1 of 2 treatment groups-paroxetine-only monotherapy group (N = 16)
or paroxetine plus 12 sessions of CBT combination therapy group (N = 19)-for a
12-week trial. Progress was monitored by a psychiatrist blinded to treatment
group, using the Hamilton Rating Scale for Depression, Hamilton Rating Scale for
Anxiety, Yale-Brown Obsessive Compulsive Scale, Clinical Global Impressions
scale, and Edinburgh Postnatal Depression Scale. Data were analyzed using
2-tailed statistical tests at an alpha level of.05. The study was conducted from
April 1, 2002, to June 30, 2003. RESULTS: Both treatment groups showed a highly
significant improvement (p <.01) in mood and anxiety symptoms. Groups did not
differ significantly in week of recovery, dose of paroxetine at remission, or
measures of depression, anxiety, and obsessive-compulsive symptoms at outcome.
CONCLUSION: Antidepressant monotherapy and combination therapy with
antidepressants and CBT were both efficacious in reducing depression and anxiety
symptoms. However, in this sample of acutely depressed/anxious postpartum women,
there were no additional benefits from combining the 2 treatment modalities.
Further research into the efficacy of combination therapy in the treatment of
moderate-to-severe depression with comorbid disorders in postpartum women is
recommended.
———-
Nervenarzt. 2004 Nov;75(11):1068-73.

[Psychotherapy for postpartum depression with a focus on mother-infant
interaction] [Article in German]

Reck C, Weiss R, Fuchs T, Mohler E, Downing G, Mundt C.

Allgemeine Psychiatrie, Psychiatrische Klinik der Universitat Heidelberg.
corinna.reck@med.uni-heidelberg.de

In the treatment of mothers with postpartum depression, mother-infant
interaction plays a central role. It is well known that babies are very
sensitive to their mothers’ emotional state. This sensitivity during the first
months of life is fundamental to understanding the influence of maternal
psychiatric disorders and especially of postpartum depression, as the most
frequent, on children’s development. The specific situation of young mothers
requires adaptation of psychotherapeutic approaches to their needs. In
connection with an overview of these issues, models of mother-infant treatment
as well as evaluation studies are discussed. Finally, an integrated treatment
approach for postpartum depression including mother-infant-centered
interventions is presented.
———-
Int J Psychiatry Med. 2003;33(4):391-4.

Treatment of perinatal delusional disorder: a case report.

Friedman SH, Rosenthal MB.

University Hospitals of Cleveland, North East Ohio Health Services, 44106, USA.
susanhfmd@hotmail.com

This article is a report on a complicated case of delusional disorder in
pregnancy and lactation, and effective multidisciplinary treatment. Few reports
in the literature concern delusional disorder in pregnancy, or regard
olanzapine’s safety in pregnancy and lactation. A gravid woman in her third
trimester merited twin diagnoses of delusional disorder and borderline
personality disorder, and was successfully treated with olanzapine and
psychotherapy during pregnancy and lactation. Her infant was large for
gestational age (LGA) and had Erb’s palsy, which resolved, and remained healthy
at six months, with continued breastfeeding. Her delusional beliefs did not
recur, nor did she have postpartum depression or psychosis.
———-
Arch Psychiatr Nurs. 2004 Apr;18(2):39-48.

Group therapy and its barriers for women suffering from postpartum depression.

Ugarriza DN.

University of Miami School of Nursing, Coral, Gables, FL 33134, USA.
dugarriza@miami.edu

Data were collected to pilot-test the feasibility and the effects of the “Gruen”
Postpartum Depression Group Therapy as an intervention for depression for a
small treatment and control group of postpartum depressed mothers. Treatment was
a ten-week group therapy consisting of four interacting aspects: (1) education
and information, (2) stress reduction techniques,(3) development of support
systems, and (4) cognitive restructuring. Beck Depression Inventory II scores
were significantly lower post treatment in the treatment group. Women stated
psychoeducation was the greatest help to them. One of the problems associated
with treating postpartum women was their inability to get to therapy because of
childcare responsibilities.
———-
Aust N Z J Psychiatry. 2004 Apr;38(4):212-8.

A comparative evaluation of community treatments for post-partum depression:
implications for treatment and management practices.

Highet N, Drummond P.

Beyondblue; The National Depression Initiative, PO Box 6100, Hawthorn West,
Victoria, 3122, Australia. nicole.highet@beyondblue.org.au

OBJECTIVE: To compare existing community treatments for post-partum depression
(PPD), treatment efficacy was evaluated for 146 women seeking treatment for PPD
in the local community. METHODS: Self-report questionnaires were designed to
assess clinical depression and anxiety (psychological and physiological), risk
factors, treatment satisfaction and the impact of social supports. RESULTS:
Comparison of treated subjects with those on a wait-list demonstrated that
depression and the psychological component of anxiety decreased significantly
after treatment. Psychological and pharmacological interventions produced
similar clinical benefit in the treatment of psychological symptoms, and
receiving both treatments in combination was of no added clinical benefit in the
immediate or longer term. Individual treatment was associated with more rapid
treatment gains initially than group treatment. However, the benefits of group
treatment emerged during the 6 months following treatment, leading both
interventions to be equally effective in the longer term. Cognitive behavioural
therapy was not superior to the combination of non-specific counselling or
behavioural strategies, either immediately following treatment or 6 months
later. CONCLUSIONS: Clinical efficacy together with other clinical and financial
benefits strongly advocate the application of psychological treatment for PPD.
Clear parallels between PPD and general depression support the application of
knowledge about general depression to extend understanding of PPD and refine
clinical management practices.
———-
J Midwifery Womens Health. 2004 Mar-Apr;49(2):96-104.

Complementary therapies as adjuncts in the treatment of postpartum depression.

Weier KM, Beal MW.

kweier@aya.yale.edu

Postpartum depression affects an estimated 13% of women who have recently given
birth. This article discusses several alternative or complementary therapies
that may serve as adjuncts in the treatment of postpartum depression. The intent
is to help practitioners better understand the treatments that are available
that their clients may be using. Complementary modalities discussed include
herbal medicine, dietary supplements, massage, aromatherapy, and acupuncture.
Evidence supporting the use of these modalities is reviewed where available, and
a list of resources is given in the appendix.
———-
Arch Psychiatr Nurs. 2003 Dec;17(6):276-83.

Role functioning and symptom remission in women with postpartum depression after
antidepressant treatment.

Logsdon MC, Wisner K, Hanusa BH, Phillips A.

School of Nursing, University of Louisville, Louisville, KY, USA. mclogs@aol.com

The primary purpose of this pilot study was to compare improvement of symptoms
and role functioning in women with postpartum depression after 8 weeks of
treatment with antidepressants. The study was a secondary data analysis from the
preliminary data of a double blind, randomized clinical trial. The participants
(n=61) were primarily Caucasian and slightly over half were married, first time
mothers, and middle- to upper-middle-class. At intake, most participants were
moderately to severely ill. At week one and week eight of the study, measures of
symptoms and functioning were only moderately correlated. After 8 weeks of
antidepressant treatment, symptoms and most measures of functional status
improved; however, improvement in one dimension did not imply improvement in the
other. Recommendations are given for clinical practice and further research in
this area.
———-
J Am Board Fam Pract. 2003 Sep-Oct;16(5):372-82.

Comment in:
MedGenMed. 2004;6(1):43.

The effectiveness of various postpartum depression treatments and the impact of
antidepressant drugs on nursing infants.

Gjerdingen D.

Department of Family Practice & Community Health, University of Minnesota, St.
Paul 55103, USA. dgjerdin@umphysicians.umn.edu

BACKGROUND: Postpartum depression is seen in approximately 13% of women who have
recently given birth; unfortunately, it often remains untreated. Important
causes for undertreatment of this disorder are providers’ and patients’ lack of
information about the effectiveness of various treatments, and their concerns
about the impact of treatment on nursing infants. This article presents
research-based evidence on the benefits of various treatments for postpartum
depression and their potential risks to nursing infants. METHODS: The medical
literature on postpartum depression treatment was reviewed by searching MEDLINE
and Current Contents using such key terms as “postpartum depression,”
“treatment,” “therapy,” “psychotherapy,” and “breastfeeding.” Results and
CONCLUSIONS: There is evidence that postpartum depression improves with
antidepressant drug therapy, estrogen, individual psychotherapy, nurse home
visits, and possibly group therapy. Of the more frequently studied
antidepressant drugs in breastfeeding women, paroxetine, sertraline, and
nortriptyline have not been found to have adverse effects on infants.
Fluoxetine, however, should be avoided in breastfeeding women. By administering
effective treatment to women with postpartum depression, we can positively
impact the lives of mothers, their infants, and other family members.
———-
Seishin Shinkeigaku Zasshi. 2003;105(9):1136-44.

[Treatment strategy for women with puerperal psychiatric
disorders–psychopharmaco-therapy and its impact on fetus and breast-fed
infants] [Article in Japanese]

Yoshida K, Yamashita H.

Department of Neuropsychiatry, Kyushu University Hospital.

Women have the most possibility of suffering from mental disorders during
pregnancy and postpartum periods in their whole life time. Especially, postnatal
depression is not uncommon with an incidence of 10-20%, fortunately a screening
system has been developed, and in Japan the Edinburgh Postnatal Depression Scale
(EPDS) is now practically used in both hospitals and community health service
centers. Additionally most mental disorders during this period are not severely
disturbed, so they do not have to be necessarily treated by psychiatrists.
Severely disturbed cases, however, which include postnatal depression with self
or infant harm thought or puerperal psychosis are to be treated by psychiatrists
and tend to have psychopharmaco-therapy. In using psychotropic drugs attention
must be paid for both women and their babies. Impact on breast-fed babies while
mothers take psychotropic drugs have been reported, mostly as case reports. We
have reported the controlled studies, (1) The 25 mothers with postnatal
depression were treated by tricyclic antidepressants, of which 10 breast-fed and
15 did not. The drugs were amitriptyline, imipramine, clomipramine, dothiepine,
(2) The 30 mothers with puerperal psychosis were treated by antipsychotic drugs,
of which 12 breast-fed and 18 did not. The drugs were chlorpromazine,
trifluoperazine, perphenazine and haloperidol. Both antidepressants and
neuroleptics were transferred through breast-milk and a few % of maternal dose
per kilogram were injected to their babies by calculating drug concentration
ratios of in breast-milk/in serum. None of the breast-fed infants had adverse
effects, and no developmental difference was found compared to bottle-fed
infants using the Bayley Development Scale during infancy. Furthermore, the
breast-fed infants were followed up as long as possible up to 30 months and no
significant developmental delay was found. In addition, we reported a case study
on four breast-fed babies whose mothers took fluoxetine. The infants had no
adverse effects. Pregnant women and their fetuses need to be more carefully
monitored. Three preliminary cases were reported here; the pregnant women took
clomipramine, sulpiride, haloperidol and chlorpromazine. Drug concentrations in
maternal plasma in late pregnancy and postnatally and in umbilical cords were
almost the same, which meant they were freely transferred from mothers to
babies. Regarding the neonate’s outcome, all were full turn born with normal
birth weight with good Apgar scores. Weight gain in one month was normal which
meant all babies had normal sucking without hypotonic muscle. Psychiatrists must
accumulate these date and contribute as one of specialists in perinatal mental
health in multi-disciplinary team.

no