Support and Training to Enhance Primary Care for Postpartum Depression

Making Clinical Decisions

Decide Who to Treat and Who to Refer

Deciding when to treat a woman with PPD or refer her to a mental health specialist depends on a variety of factors, including provider, patient, and treatment setting. Referral to a mental health specialist is advised under the following circumstances:

Patient Factors
  • Severe depression
  • Suicidality or thoughts of hurting self or baby
  • Presence of psychosis
  • Comorbid active psychological conditions (e.g., substance abuse, bipolar disorder)
  • History of domestic violence or current abuse in the home
Provider and Setting Factors
  • Provider lacks education, training, or comfort in treating PPD
  • Provider has limited time and other resources available
  • Distance from the patient’s residence to the provider’s office prohibitive for regular visits; qualified mental health specialists located closer to the patient's home
  • Provider unable to see the patient regularly or schedule the necessary follow-up visits
Patient and Community Resources
  • Patient’s adequate insurance coverage for mental health specialty services
  • An adequate pool available of therapists, psychiatrists, and other specialists in the area
  • Patient’s access to support groups, home care, and other services

As a general rule, if the patient reports significantly impaired functioning (for example, scoring higher than 20 on the EPDS), endorses suicidal thoughts, reports domestic abuse, or shows signs of psychosis, another risk assessment is necessary immediately. If you deem the mother to be at a high risk for harming herself or her baby, it may not be safe for her to go home. Follow the protocol for crisis intervention.

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Introduce Treatment Options to the Patient

Regardless of the role you play in treatment you should discuss treatment options and your recommendations directly with your patient, along with your recommendations, so that she and her family may make informed decisions about treatment. Open the conversation by asking the patient about any preferences she has regarding treatment. These questions might include:

  • If we were to begin a treatment for depression, what kind of treatment would you feel most comfortable using?
  • Have you ever been treated for depression before? If so, what treatments for depression have you tried?
  • Were any of those treatments helpful? Did you experience any side effects or problems with any of the treatments?
  • Has anyone in your family had treatment for depression? What worked for them?
  • Are you currently breastfeeding? (This may affect medication preferences.)  
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Collaboratively Decide Which Treatment Method to Employ

The decision about what treatment to initiate will depend on a number of factors, including the patient’s preference and personal circumstances and history, your comfort and experience with various modes of treatment, and the availability of experienced mental health professionals in the area. Here are some general guidelines for deciding if psychotherapy, medication, or a combination should be used first:

  • Previous Experiences: Take both positive and negative experiences with previous treatments into consideration. Whenever possible, use treatments with which the patient has had prior success.
  • Patient Preference: Patients are more likely to comply with treatment and report satisfaction with the treatment process when their preferred method of treatment is used. Women may prefer to receive medication or treatment from a primary care provider rather than a mental health specialist, because of issues of stigma related to seeing a mental health specialist.
  • Insurance: Consider how much the patient would have to pay out-of-pocket for medications or psychotherapy, and whether the patient has coverage for the specific medications or psychotherapies.
  • Generally, patients with mild to moderate depression without suicidal thoughts or psychosis benefit from psychotherapy or medication, while those with more severe depression and/or past histories of depression should be treated with medication or combination therapy.