Table 2.

Key general management considerations for postpartum depression

1. Factors to consider when planning treatment:
• Severity of depressive signs and symptoms			• Concurrent medical and psychiatric diagnoses
• Prior depression history/response to treatment			• Current medications (including over-the-counter)
• Patient preferences regarding treatment			• Local mental healthcare resources
• Severity of depressive signs and symptoms			• Psychosocial supports
• Choices about breastfeeding
2. Involve the patient’s support system in treatment planning decisions, when appropriate.
3. Consider case management or care coordinator for women who are eligible for such services based on economic, logistic, and clinical factors.
4. Generate a reasonable menu of treatment options based on depressive symptom severity and decision to breastfeed. For example:
Severity	Breastfeeding (Y/N)	Options
Mild to moderate	Yes or No	Psychotherapy (interpersonal [IPT] or cognitive-behavioral therapy [CBT]) considered first-line. Weaker evidence supports non-directive counseling for short-term benefit
Moderate to severe	No	Antidepressant medication, with or without psychotherapy Psychotherapy alone is still reasonable for many, so long as depressive symptoms are carefully tracked. Adding an antidepressant becomes higher priority in patients not responding well to psychotherapy
Moderate to severe	Yes	Antidepressant medication, with or without psychotherapy Many women elect not to receive antidepressants. If this occurs, psychotherapy alone is still reasonable, so long as depressive symptoms are carefully tracked. Antidepressants are higher priority when depressive symptoms persist or worsen in spite of non-pharamacological treatment, or when depressive symptoms are severe Hospitalization, antipsychotic medication, and/or ECT if psychotic symptoms are present
5. Consider other psychosocial treatment options based on individual patient factors and available resources.
Consider…	When…
Group psychotherapy	Depressive symptoms are mild to moderate May benefit patients who struggle with isolation and low psychosocial support
Marital or couples therapy	Same as above, but prioritize if marital strain or difficulties with partner are clearly contributing to depression IPT can address interpersonal contributors to depression if the patient prefers an individual psychotherapy approach, if the spouse/partner is unwilling or unavailable for therapy, or if local resources do not support marital/couples therapy.
Non-directive counseling	Depressive symptoms are mild, and symptoms can be carefully tracked Other resources are available should longer-term depression management be needed
Community supports	These are not generally considered stand-alone treatments for PPD. Local support groups and organizations can be helpful by providing peer-to-peer support and, occasionally, assistance with logistical difficulties
6. When choosing among antidepressants, consider past treatment response and available lactational safety data:
Previously effective antidepressants (PPD or non-puerperal major depression) should generally be given higher priority. Otherwise, sertraline, paroxetine, fluvoxamine, and nortriptyline have the most evidence of lactation safety based on low (though not absent) infant exposure through breastfeeding and fewest reported adverse effects.
7. Nursing infants of mothers who are treated with antidepressants should be monitored for side effects (below). Infant blood levels of antidepressants do not generally need to be monitored.
• Drowsiness			• Poor feeding
• Irritability			• Poor weight gain
8. Consider referral to specialty mental health services when:
• Severe depression			• Suicidal or homicidal ideation (urgent)
• Depression not responding to first-line treatment			• Infanticidal ideation (urgent)
• Comorbid anxiety or obsessions			• Psychotic signs and symptoms (urgent)
• Comorbid substance abuse
• Bipolar disorder suspected			• When uncomfortable managing the case