Treating postpartum depression. (Drugs, Pregnancy, and Lactation).

Postpartum depression, which has a prevalence between 5% and 10%, is characterized by depressive symptoms similar to those associated with major depression in the general population. Symptoms may begin early after delivery or, occasionally late in pregnancy.

The cause is not entirely dear; multiple factors, both psychosocial and neuromodulatory, are probably involved. Although many researchers have tried to attribute the disorder to the rapid hormonal changes that occur at this time, particularly the dramatic fall in estrogen, there are few data directly linking postpartum depression to these changes.

What is clear is that postpartum depression is an easily detectable illness that is highly prevalent but vastly undertreated. Only a few clinical trials have evaluated antidepressants in this patient population, which is extraordinary, considering the hundreds of trials that have evaluated antidepressants.

In the literature, there are three clinical trials of antidepressants for postpartum depression: A double-blind placebo-controlled study of fluoxetine (Prozac), an open study of sertraline (Zoloft), and an open study of immediate-release venlafaxine (Effexor). All three studies were positive and suggested robust responses to antidepressants.

For example, in our 8-week study of 15 women with a major depressive disorder who were treated with immediate-release venlafaxine, 12 had a remission (J. Chin. Psychiatry 62[8]:592-96, 2001). The results were similar to those observed clinically: Many women with postpartum depression, when identified and treated early can have a marked, rapid response to an antidepressant, including those with severe depression. (The study was supported by a grant from Wyeth-Ayerst Laboratories).

A major issue is whether there is a role for hormonal therapy Currently there are very few data that support the use of estrogen to treat women with postpartum depression or as a prophylactic treatment for those with a past history of postpartum depression. There may be a subset of women who have an exquisite sensitivity to postpartum hormonal changes, particularly rapid estrogen withdrawal, who may respond to estrogen post partum, but this population has not been well identified.

Therefore, given the literature on the effectiveness of antidepressants for depression in general, antidepressants should be considered the treatment of choice. Nonpharmacologic therapies, such as interpersonal psychotherapy may ...