Support and Training to Enhance Primary Care for Postpartum Depression

Models/Methods of Treatment in Primary Care Settings

Earlier in this module, we discussed the literature on various treatment modalities and their effectiveness. This section provides general guidelines and an overview of the types of treatment for PPD used in primary care settings. This information should be used in conjunction with other training, consultations, or supplemental instruction on caring for women with mood disorders during the postpartum period, as well as your best clinical judgment.

Pharmacological Treatments

Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) are most commonly prescribed for PPD because they have larger databases supporting safety during breastfeeding. These and other antidepressants include:

  • SSRIs: sertraline, citalopram, paroxetine, fluoxetine, and fluvoxamine
  • TCAs: amitriptyline, nortriptyline, imipramine, and desipramine
  • Others: venlafaxine, duloxetine, buproprion, and mirtazepine
Name of Medication Classification Typical Dose Common Side Effects
Sertraline
(Zoloft)
Selective Serotonin Reuptake Inhibitor 50–150mg per day Headache, nausea, sexual dysfunction
Citalopram
(Celexa, Lexapro)
Selective Serotonin Reuptake Inhibitor 20–60mg per day (Celexa)
10–30 mg per day
(Lexapro)
Headache, nausea, sexual dysfunction
Paroxetine
(Paxil)
Selective Serotonin Reuptake Inhibitor 20–60 mg per day Headache, nausea, sexual dysfunction
Fluvoxamine
(Luvox)
Selective Serotonin Reuptake Inhibitor 50–200 mg per day Headache, nausea, sexual dysfunction
Fluoxetine
(Prozac)
Selective Serotonin Reuptake Inhibitor 20–80 mg per day Headache, nausea, sexual dysfunction
Amitriptyline
(Elavil)
Tricyclic Antidepressant 50–200 mg per day Dry mouth, constipation, sedation
Nortriptyline
(Aventyl)
Tricyclic Antidepressant 50–200 mg per day Dry mouth, constipation, sedation
Imipramine
(Tofranil)
Tricyclic Antidepressant 50–200 mg per day Dry mouth, constipation, sedation
Desipramine
(Pertofrane)
Tricyclic Antidepressant 50–200 mg per day Dry mouth, constipation, sedation
Buproprion
(Wellbutrin)
Atypical Antidepressant 100–300mg per day Headache, nausea, insomnia
Venlafaxine
(Effexor)
Selective Serotonin and Norepinephrine Reuptake Inhibitor 75–300mg per day Nausea, headache
Duloxetine
(Cymbalta)
Selective Serotonin and Norepinephrine Reuptake Inhibitor 20–60mg per day Nausea, headache
Mirtazepine
(Remeron)
Atypical Antidepressant 15–45mg per day Sedation, increased appetite
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Many patients have concerns about starting a trial of antidepressant medication. These include: 139

  • Becoming dependent on the medication
  • Past negative experiences and/or side effects with medications
  • Fear of taking medications while breastfeeding

Patients may also have problems with compliance once starting treatment:

  • The patient may stop taking medication when she feels better.
  • The patient may stop taking medication after a few days if she does not feel better right away.
  • The patient may stop taking medication because of transient or long-term side effects.

Additional considerations also need to be discussed with the patient before initiating a medication trial when she is a breastfeeding mother:

  • Although well-studied and recommended for use in many professional guidelines, the use of SSRIs and TCAs while breastfeeding has not been approved by the FDA: 30
    • Most SSRIs, namely sertraline, citalopram, paroxetine, and fluvoxamine, have not been associated with health problems for breastfeeding infants. 95
    • The TCAs with the fewest side effects that are most commonly prescribed for breastfeeding women are nortriptyline and desipramine. 143
    • The SSRI fluoxetine has been reported in several cases to accumulate in breastfeeding infants and generally should not be considered a first-line treatment unless the woman has a history of good response to fluoxetine.
  • Lactating women should use the lowest therapeutically effective dose possible since antidepressants are secreted (albeit in trace amounts) in breast milk. 91
    • Studies show SSRIs and TCAs are not generally found in measurable amounts in breastfeeding babies. 121
    • There have been case reports of fluoxetine causing decreased weight gain and colic in breastfeeding babies. 21
  • Observing infant behavior before initiating use can provide a baseline to determine if the baby is affected by treatment. 121
    • No developmental problems have been found in children exposed to TCAs or SSRIs through breast milk.
  • A pediatrician, family physician, or other provider should follow the baby and monitor for side effects secondary to medication in breast milk, and should be informed when there is a medication change.
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Psychotherapy Treatments

  • Psychotherapy should be considered a first-line treatment for PPD.
  • Providers should develop a network of psychotherapists that they know and trust.
  • Psychotherapists should be well trained and familiar with empirically validated treatments.
Interpersonal Psychotherapy 38 81
  • Interpersonal Psychotherapy (IPT) is an effective treatment for mild to severe PPD, especially when initiated early.
  • The efficacy of IPT may be enhanced when used in combination with pharmacological treatments
  • IPT can be conducted in groups or individually
  • Typical treatment with IPT lasts 12-14 weeks; maintenance treatment may help prevent a relapse
  • The benefits of IPT include:
    • Improved maternal role adjustment and relationships with family members
    • Enhanced communication skills and maternal self-esteem
  • The focus of IPT can include:
    • The patient's current interpersonal relationships
    • The role of transition that results from pregnancy and birth
    • Any losses associated with pregnancy and birth
    • Reinforcing the patient's self-efficacy and coping skills in overcoming depression
    • Improving the patient's social support
    • Planning a course of action in the event of a relapse
Cognitive Therapy or Cognitive-Behavioral Therapy 54 82 125
  • Cognitive-Behavioral Therapy (CBT) is not as widely studied for PPD as Interpersonal Psychotherapy (IPT), so its efficacy is not as well established
  • CBT may be most suitable for patients with mild to moderate PPD
  • CBT can be conducted in groups or individually
  • Typical treatment with CBT lasts 12-14 weeks; maintenance treatment may help prevent a relapse
  • The possible benefits of CBT include:
    • Patient identifies her beliefs about herself, others, and the future, which are distorted by depression
    • New behaviors and attitudes are learned to change those beliefs
  • The focus of CBT includes:
    • Problems identified by the mother regarding infant care and/or her maternal role
    • Problem-solving advice about managing identified problems
    • Evaluation of the patient's thoughts and behaviors
    • Formation of short- and long-term goals
    • Modeling and reinforcement for improving maternal adjustment
Marriage or Family Therapy
  • Maternal depressive symptoms can have a negatively impact on family dynamics 45
  • Paternal depression is not uncommon (it occurs at about half the rates of PPD in women), especially for men whose partners are experiencing PPD
  • Partner support, whether actual or perceived, can increase a woman's self-esteem and satisfaction with her role as a woman, partner, and mother 45
  • Addressing changes brought about by the birth of a newborn in the entire family unit can be beneficial for all members 88
Social Support or Support Groups 107
  • Support groups have been shown to reduce depressive symptoms only for women with mild depression 33
  • Formal or informal social support networks can consist of family members, friends, healthcare providers, other new mothers, etc.
  • Faith-based support may have particular benefits for some women 95
  • A peer-to-peer, telephone-based support system can help pair new mothers with women who have previously experienced PPD
  • The possible benefits of social support or support groups include: 95
    • Increased self-esteem
    • Reduced feelings of isolation and stigma
    • Normalization of symptoms/feelings through expressions of empathy and empowerment 52
    • Does not "feel" like therapy
  • Focus of support group or peer-to-peer network can include 134 :
    • Transition to maternal role: introductions, general experiences since birth, mood changes
    • Stress management during postpartum period: birth-related stress, child care, role changes
    • Communication skills: tips for communicating with spouses, parents, in-laws, and others
    • Life planning: value systems, changes, and strategies for achieving changes
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Alternatives to Pharmacological and Psychotherapeutic Treatments 52 130

Electroconvulsive therapy
  • This therapy is an effective and empirically validated treatment for PPD and postpartum psychosis
  • Initiation requires referral to a psychiatrist
  • The typical course of treatment is 6 to 12 treatments spaced every 2 to 3 days; some patients need treatment for up to 2 to 4 months
  • Generally used for women who have failed conventional treatment with antidepressants or for those experiencing psychotic symptoms
Light therapy
  • This therapy may be helpful for women with mild PPD
  • Melatonin, cortisol, thyroid-stimulating hormone, and prolactin may be involved
  • This therapy is most successful with patients experiencing Seasonal Affective Disorder
  • Patient is exposed to a bright fluorescent light (10,000 lux) for 30 minutes per day
  • Mood improvement can be experienced within 2 days to 3 weeks of treatment
  • This therapy may be used as an adjunctive treatment for medication or psychotherapy
  • If symptoms do not lessen within 4 weeks, another therapy should be initiated
Wake therapy or sleep deprivation therapy
  • This therapy may be helpful for women with mild PPD
  • Treatment involves reinstating the synchronization of circadian rhythms
  • This therapy may affect melatonin, cortisol, thyroid-stimulating hormone, and prolactin
  • Still experimental, but the results of pilot studies have been promising
  • Symptoms of depression may worsen after sleep deprivation for some patients
  • This therapy may not be suitable for women with a newborn child or other children
Acupuncture
  • Still experimental, but the results of pilot studies have been promising
Nutritional changes and exercise
  • These should always be included as recommendations for PPD
  • They are not sufficient to treat PPD by themselves
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Ruling Out Other Causes of PPD Symptoms

It is imperative to address and rule out medical or other psychological sources of PPD symptoms, as the course of treatment will vary greatly if the symptoms do not result  from PPD. Please consider and rule out the following before starting any medication regimen:

  • Bipolar disorder (antidepressant use increases the risk of developing a manic episode)
  • Psychotic illness or schizophrenia spectrum disorders (i.e., schizoaffective disorder)
  • Thyroid disorder s
  • Side effects of oral contraceptives
  • Side effects of anticonvulsant medications
  • Side effects of Reglan or other medications
  • Vitamin deficiencies or other lab irregularities
  • Diabetes
  • Autoimmune and other medical disorders

Also, you must monitor the patient very closely for any signs of suicidal thoughts, as antidepressants have been shown to increase these thoughts in some patients.

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Hormonal Treatments 68

  • Thyroid function should always be assessed with PPD. It is estimated that up to 10 percent of women with PPD develop depression secondary to hypothyroidism.
  • Natural fluctuations in hormones are normal during and after pregnancy but can contribute to PPD; ask women if they are breastfeeding or just stopped breastfeeding as both can affect hormone levels and mood.
  • There is little evidence to support either estrogen or progesterone for the treatment of PPD.
  • Hormones should be used only as adjunct treatment for women who fail to respond to conventional treatments.
  • Treatment with estrogen, in particular, during the postpartum increases risk for hypercoagulation.
  • Breastfeeding mothers should consider that:
    • High doses of estrogen can elevate levels of steroids in breast milk and contribute to jaundice.
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Case Management and Treatment of PPD in Primary Care

  • Nurses 67 and social workers 9 are often the most effective case managers in primary care settings.
  • The case manager can maintain contact with all providers involved in the patient's care and facilitate communication between them
  • The role of the case manager is to: 127
    • Provide patient education and counseling regarding treatment
    • Improve patient adherence to treatment
    • Track progress through treatment
    • Facilitate follow-up with chart notations for provider
  • Telephone follow-up in case management can increase patient adherence to treatment 17
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Collaborative Care

What is Collaborative Care?
  • Collaborative care involves shared treatment between the provider and a mental health specialist to improve clinical outcomes 35
  • Members of the collaborative care team can include:
    • Woman’s primary care provider
    • Baby’s primary care provider
    • Mental health specialist
    • Case manager
    • Others, as necessary
How Does Collaborative Care Work?
  • Stepped collaborative care tailors treatment styles to meet different women’s needs: 35
    • The provider gives brief patient education and counseling during clinical visits, prescribes medication to treat symptoms, and monitors patient outcomes.
    • The case manager or mental health specialist provides additional education and counseling, either in person or over the telephone, to enhance adherence to treatment and monitor treatment outcomes.
    • The provider refers the patient to a mental health professional for treatment and follow-up.
  • A mental health referral network is an essential element of collaborative care:
    • Learn about and cultivate professional relationships with the mental health specialists in the area who are familiar with PPD, its clinical presentation, and effective treatment options.
    • This may be more difficult in rural settings where there is a lack of mental health specialists. 95
    • Having a mental health specialist on staff in a primary care setting can enhance professional communication between collaborative care partners. 46
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