Abstract
Introduction: Mother with postnatal depression is not able to adequately respond to the needs of her child. Maternal depression poses a serious health & safety risk for mother and child. They both need treatment with rapid onset of action and minimal influence on the infant.
Aim: Discussion of professional boards’ recommendations together with RCT results and clinical observations reffering to nursing depressed women with emphasis on practical aspects and future directions.
Methods: Discussion on postnatal depression treatment national guidelines and results from meta-analyses and systematic reviews found in Pubmed and Cochrane databases with "postanatal" or "postpartum" or "puerperium" and "depression" keywords. Selection of articles based on practical aspects of management.
Results: Despite its widespread use, the safety and efficacy of SSRIs in postpartum mood disorders have not yet been clearly confirmed. Long-term observation of behaviour and development of children after early exposure to SSRIs up to adulthood is necessary to fully assess the risk of antidepressant treatment in nursing mothers.
Conclusions: Pharmacotherapy remains the most accessible method of treating depression in the puerperal period, however, knowledge about the safety of antidepressants during lactation is still insufficient. Individualization of treatment depending on the patient's condition, specific needs, availabity of procedures and mental or physical comorbidity is necessary.
References
(1) Samochowiec J, Rybakowski J, Galecki P, et al. Recommendations of the Polish Psychiatric Association for treatment of affective disorders in women of childbearing age. Part I: Treatment of depression. Psychiatr Pol 2019 Apr 30; 53(2):245-262. DOI:10.12740/PP/103385. Epub 2019 Apr 30. English, Polish. PMID:31317956.
(2) Rozporządzenie Ministra Zdrowia z dnia 16 sierpnia 2018 r. w sprawie standardu organizacyjnego opieki okołoporodowej. Dz. U. 2018, poz. 1756.
(3) Jarema M. [red.]: Standardy leczenia farmakologicznego niektórych zaburzeń psychicznych. Wydawnictwo Via Medica; Gdańsk 2015, wydanie drugie.
(4) Weinberg MK, Tronick EZ. The impact of maternal psychiatric illness on infant development. J Clin Psychiatry 1998; 59 Suppl 2:53-61. Review. PMID:9559760.
(5) Kadriu B, Deng ZD, Kraus C, Henter ID, Lisanby SH, Zarate CA. Not So Fast: Recent Successes and Failures in Treating Depression. J Clin Psychiatry. 2020 May 26; 81(4):19ac13138. DOI:10.4088/JCP.19ac13138. PMID:32459405.
(6) Oates M. Suicide: the leading cause of maternal death. Br J Psychiatry 2003 Oct; 183:279-81. PMID:14519602.
(7) d'Orbán PT. Women who kill their children. Br J Psychiatry 1979 Jun; 134:560-71.
(8) Cooper PJ, Murray L. Course and recurrence of postnatal depression. Evidence for the specificity of the diagnostic concept. Br J Psychiatry 1995 Feb; 166(2):191-195.
(9) MacQueen GM, Frey BN, Ismail Z, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: Section 6. Special populations: Youth, women, and the elderly. Can J Psychiatry 2016; 61(9):588-603.
(10) Accortt EE, Cheadle AC, Dunkel Schetter C. Prenatal depression and adverse birth outcomes: an updated systematic review. Matern Child Health J 2015 Jun; 19(6):1306-37. DOI:10.1007/s10995-014-1637-2. Review. PMID:25452215.
(11) Suri R, Lin AS, Cohen LS, Altshuler LL. Acute and long-term behavioral outcome of infants and children exposed in utero to either maternal depression or antidepressants: a review of the literature. J Clin Psychiatry 2014 Oct; 75(10):e1142-52. DOI:10.4088/JCP.13r08926. Review. PMID:25373125.
(12) Brummelte S, Galea LA. Postpartum depression: Etiology, treatment and consequences for maternal care. Horm Behav 2016 Jan; 77:153-66. DOI:10.1016/j.yhbeh.2015.08.008. Epub 2015 Aug 28. Review. PMID:26319224.
(13) Pużyński S, Wciórka J. Klasyfikacja zaburzeń psychicznych i zaburzeń zachowania w ICD-10. Opisy kliniczne i wskazówki diagnostyczne. Stanisław Pużyński, Jacek Wciórka 83-85688-25-0 WydawnictwoVesalius; Kraków 2000, wyd.2.
(14) BC Reproductive Mental Health Program. Best Practice Guidelines for Mental Health Disorders in the Perinatal Period. Vancouver, BC, Canada: BC Reproductive Mental Health; 2014.
(15) Nederlandse Vereniging voor Obstetrie en Gynaecologie. Richtlijn: SSRI-gebruik in de zwangerschap en tijdens de lactatie. North Padre Island, TX: Nederlandse Vereniging voor Obstetrie en Gynaecologie; 2012.
(16) National Collaborating Centre for Mental Health. Antenatal and Postnatal Mental Health: The NICE Guideline on Clinical Management and Service Guidance. London: British Psychological Society and Royal College of Psychiatrists; 2014.
(17) Van Weel-Baumgarten EM, Van Gelderen MG, Grundmeijer HGLM, et al. NHG-Standaard Depressie (tweede herziening). Huisarts Wet 2012; 55:252-259.
(18) Weissman AM, Levy BT, Hartz AJ, et al. Pooled analysis of antidepressant levels in lactating mothers, breast milk and nursing infants. Am J Psychiatry 2004; 161:1066-107.
(19) Bazire S. Psychotropic Drug Directory 2018: The Professionals' Pocket Handbook and Aide Memoire. Lloyd-Reinhold Publications Limited 2018.
(20) Davanzo R, Copertino M, De Cunto A et al. Antidepressant drugs and breastfeeding: A review of the literature. Breastfeed Med 2011; 6:89-98.
(21) Wisner KL, Perel JM, Blumer J Serum sertraline and N-desmethylsertraline levels in breast-feeding mother-infant pairs Am J Psychiatry 1998; 155:690-692.
(22) Epperson N, Czarkowski KA: Ward-O’Brien D, et al. Maternal sertraline treatment and serotonin transport in breast-feeding mother-infant pairs. Am J Psychiatry 2001; 158:1631-1637.
(23) Women’s Health Research. Food and Drug Administration Web site. List of Pregnancy Exposure Registries. US Department of Health and Human Services. Web site http://www.fda.gov/ScienceResearch/SpecialTopics/WomensHealthResearch/ucm134848.htm.
(24) Pinheiro E, Bogen DL, Hoxha D, et al. Sertraline and breastfeeding: Review and meta-analysis Arch. Womens Ment Health 2015; 18(2):139-146.
(25) Ministry of Health, Social Services and Equality. Clinical Practice Guideline on the Management of Depression in Adults: SNS Clinical Practice Guidelines. Madrid: Ministry of Health, Social Services and Equality 2014.
(26) Marshall AM, Nommsen-Rivers LA, Hernandez LL, et al. Serotonin transport and metabolism in the mammary gland modulates secretory activation and involution. J Clin Endocrinol Metab 2010 Feb; 95(2):837-46. DOI:10.1210/jc.2009-1575. Epub 2009 Dec 4.
(27) Molyneaux E, Howard LM, McGeown HR, et al. Antidepressant treatment for postnatal depression. Cochrane Database Syst Rev 2014; (9):CD002018.
(28) Dansk Psykiatrisk Selskab, Dansk Selskab for Obstetrik og Gynaekologi, Dansk Paediatrisk Selskab, Dansk Selskab for Klinisk Farmakologi. Anvendelse af psykofarmaka ved graviditet og amning – kliniske reningslinjer. Edition 27.10.2014.
(29) Egen-Lappe V, Hasford J. Drug prescription in pregnancy: analysis of a large statutory sickness fund population. Eur J Clin Pharmacol 2004 Nov; 60(9):659-66. Epub 2004 Oct 7.
(30) Mitchell AA, Gilboa SM, Werler MM, et al. National Birth Defects Prevention Study. Medication use during pregnancy, with particular focus on prescription drugs: 1976-2008. Am J Obstet Gynecol 2011 Jul; 205(1):51.e1-8. DOI:10.1016/j.ajog.2011.02.029. Epub 2011 Apr 22. PMID: 21514558.
(31) De Crescenzo F, Perelli F, Armando M, Vicari S. Selective serotonin reuptake inhibitors (SSRIs) for post-partum depression (PPD): a systematic review of randomized clinical trials. J Affect Disord 2014 Jan; 152-154:39-44. DOI:10.1016/j.jad.2013.09.019. Epub 2013 Oct 5.
(32) Hayes RM, et al. Maternal antidepressant use and adverse outcomes: a cohort study of 228,876 pregnancies. American journal of obstetrics and gynecology 2012; 207(1):49 e1-49 e9. PubMed: 22727349.
(33) Oberlander TF, et al. Pain reactivity in 2-month-old infants after prenatal and postnatal serotonin reuptake inhibitor medication exposure. Pediatrics. 2005; 115(2):411-425. PubMed: 15687451.
(34) Pawluski JL, et al. Prenatal SSRI exposure alters neonatal corticosteroid binding globulin, infant cortisol levels, and emerging HPA function. Psychoneuroendocrinology 2012; 37(7):1019-1028. PubMed: 22177580.
(35) Weikum WM, et al. Prenatal serotonin reuptake inhibitor (SRI) antidepressant exposure and serotonin transporter promoter genotype (SLC6A4) influence executive functions at 6 years of age. Front Cell Neurosci 2013; 7:180. PubMed: 24130516.
(36) Meltzer-Brody S, Colquhoun H, Riesenberg R, et al. Brexanolone injection in post-partum depression: two multicentre, double-blind, randomised, placebo-controlled, phase 3 trials. Lancet 2018; 392:1058-1070.
(37) Cooper MC, Kilvert HS, Hodgkins P, Roskell NS, Eldar-Lissai A. Using Matching-Adjusted Indirect Comparisons and Network Meta-analyses to Compare Efficacy of Brexanolone Injection with Selective Serotonin Reuptake Inhibitors for Treating Postpartum Depression. CNS Drugs 2019 Oct; 33(10):1039-1052. DOI:10.1007/s40263-019-00672-w. PMID:31642037.
(38) Cooper MC, Kilvert HS, Hodgkins P, et al. Using Matching-Adjusted Indirect Comparisons and Network Meta-analyses to Compare Efficacy of Brexanolone Injection with Selective Serotonin Reuptake Inhibitors for Treating Postpartum Depression. CNS Drugs. 2019 Oct; 33(10):1039-1052. DOI:10.1007/s40263-019-00672-w.
(39) Lin PY, Mischoulon D, Freeman MP, et al. Are omega-3 fatty acids antidepressants or just mood-improving agents? The effect depends upon diagnosis, supplement preparation, and severity of depression. Mol Psychiatry 2012; 17:1161-1163.
(40) Bloch MH, Hannestad J Omega-3 fatty acids for the treatment of depression: Systematic review and meta-analysis. Mol Psychiatry 2012; 17:1272-1282.
(41) Grosso G, Galvano F, Marventano S, et al. Omega-3 fatty acids and depression: scientific evidence and biological mechanisms. Oxid Med Cell Longev 2014; 2014:313570. DOI:10.1155/2014/313570. Epub 2014 Mar 18. Review. PMID:24757497.
(42) Sarris J, Logan AC, Akbaraly TN, et al. Nutritional medicine as mainstream in psychiatry. Lancet Psychiatry 2015; 2:271-274.
(43) Sarris J, Logan AC, Akbaraly TN, et al. International Society for Nutritional Psychiatry Research consensus position statement: Nutritional medicine in modern psychiatry. World Psychiatry 2015; 14:370-371.
(44) Vaziri, F, Nasiri, S, Tavana, Z et al A randomized controlled trial of vitamin D supplementation on perinatal depression: In Iranian pregnant mothers. BMC Pregnancy Childbirth 2016; 16, 239.
(45) Terman M, Terman JS Light therapy for seasonal and non-seasonal depression: efficacy, protocol, safety, and side effects. CNS Spectr 2005; 10:647-663.
(46) Golden RN, Gaynes BN, Ekstrom RD, et al. The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Am J Psychiatry 2005; 162:656-662.
(47) Tuunainen A, Kripke DF, Endo T, et al. Light therapy for non-seasonal depression. Cochrane Database Syst Rev 2004; 2:CD004050.
(48) Rastad C, Ulfberg J, Lindberg P: Improvement in fatigue, sleepiness, and health-related quality of life with bright light treatment in persons with seasonal affective disorder and subsyndromal SAD. Depress Res Treat 2011; 2011:543906.
(49) Phipps-Nelson J, Redman JR, Dijk DJ, Rajaratnam SM: Daytime exposure to bright light, as compared to dim light, decreases sleepiness and improves psychomotor vigilance performance. Sleep 2006; 26:695-700.
(50) Vandewalle G, Balteau E, Phillips C, et al. Daytime light exposure dynamically enhances brain responses. Curr Biol 2006; 16:1616-1621.
(51) Espiritu RC, Kripke DF, Ancoli-Israel S, et al. Low illumination experienced by San Diego adults: association with atypical depressive symptoms. Biol Psychiatry 1994; 35:403-407.
(52) Wang EJ, Kripke DF, Stein MT, Parry BL: Measurement of illumination exposure in postpartum women. BMC Psychiatry 2003; 3:1-7.
(53) Sylvenm SM, Papadopoulos FC, Olovsson M, et al. Seasonality patterns in postpartum depression. Am J Obstet Gynecol 2011, 204:e1-e6.
(54) Parry BL, Meliska CJ, Sorenson DL, et al. Plasma melatonin circadian rhythm disturbances during pregnancy and postpartum in depressed women and women with personal or family histories of depression. Am J Psychiatry 2008; 165:1551-1558.
(55) Meltzer-Brody S. New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci 2011; 13:89-100.
(56) Ahokas A, Kaukoranta J, Wahlbeck K, Aito M Estrogen deficiency in severe postpartum depression: successful treatment with sublingual physiologic 17beta-estradiol: a preliminary study. J Clin Psychiatry 2001; 62:332-336.
(57) Kripke DF, Elliott JA, Youngstedt SD, et al. Weak evidence of bright light effects on human LH and FSH. J Circadian Rhythms 2010; 8:1-9.
(58) Corral M, Kuan A, Kostaras D. Bright light therapy’s effect on postpartum depression. Am J Psychiatry 2000; 157:303-304.
(59) Corral M, Wardrop AA, Zhang H, et al. Morning light therapy for postpartum depression. Arch Womens Ment Health 2007; 10:221-224.
(60) Anderson EL, Reti IM. ECT in pregnancy: a review of the literature from 1941 to 2007. Psychosom Med 2009; 71:235-42.
(61) Coshal S, Jones K, Coverdale J, Livingston R. An Overview of Reviews on the Safety of Electroconvulsive Therapy Administered During Pregnancy. J Psychiatr Pract 2019 Jan; 25(1):2-6. DOI:10.1097/PRA.0000000000000359. PMID:30633726.
(62) Focht A, Kellner CH. Electroconvulsive therapy (ECT) in the treatment of postpartum psychosis. J ECT 2012; 28:31-3.
(63) Sinha P, Goyal P, Andrade C. A Meta-review of the Safety of Electroconvulsive Therapy in Pregnancy. J ECT 2017 Jun; 33(2):81-88. DOI:10.1097/YCT.0000000000000362.
(64) Thyen A, Narang P, Sarai S, et al. Electroconvulsive Therapy During Pregnancy. Prim Care Companion CNS Disord. 2017 Jul 13; 19(4). pii:17br02096. DOI:10.4088/PCC.17br02096.
(65) Goldstein HH, Weinberg J, Sankstone MI. Shock therapy in psychosis complicating pregnancy: a case report. Am J Psychiatry 1941; 98:201-202.
(66) Protheroe C. Puerperal psychoses: a long term study 1927-1961. Br J Psychiatry 1969; 115:9-30.
(67) Forray A, Ostroff RB. The use of electroconvulsive therapy in postpartum affective disorders. J ECT 2007; 23:188-93.
(68) Babu GN, Thippeswamy H, Chandra PS. Use of electroconvulsive therapy (ECT) in postpartum psychosis – a naturalistic prospective study. Arch Womens Ment Health 2013; 16:247-51.
(69) Reed P, Sermin N, Appleby L, Faragher B. A comparison of clinical response to electroconvulsive therapy in puerperal and non-puerperal psychoses. J Affect Disord 1999; 54:255-256.
(70) Gressier F, Rotenberg S, Cazas O, Hardy P. Postpartum electroconvulsive therapy: a systematic review and case report. Gen Hosp Psychiatry 2015 Jul-Aug; 3(4):310-4. DOI:10.1016/j.genhosppsych.2015.04.009. Epub 2015 Apr 16.
(71) McClintock SM, Choi J, Deng ZD, et al. Multifactorial determinants of the neurocognitive effects of electroconvulsive therapy. J ECT 2014; 30:165-76.
(72) Impastato DJ, Gabriel AR Electroshock therapy during the puerperium. J Am Med Assoc 1957 Mar 23; 163(12):1017-22.
(73) Nitsun M, Szokol JW, Saleh HJ, et al. Pharmacokinetics of midazolam, propofol, and fentanyl transfer to human breast milk. Clin Pharmacol Ther 2006; 79:549-557.
(74) Rabheru K. The use of electroconvulsive therapy in special patient populations. Can J Psychiatry 2001; 46:710-719.
(75) Nobler MS, Sackeim HA, Moeller JR, et al. Quantifying the speed of symptomatic improvement with electroconvulsive therapy: comparison of alternative statistical methods. Convuls Ther 1997; 13:208-21.
(76) Bourgon LN, Kellner CH. Relapse of depression after ECT: a review. J ECT 2000; 16:19-31.
(77) Baker AA. Admitting schizophrenic mothers with their babies. Lancet 1961; 2:557-558.
(78) Cazas O, Glangeaud-Freudenthal NM. The history of Mother-Baby Units (MBUs) in France and Belgium and of the French version of the Marce checklist. ArchWomens Ment Health 2004; 7:53-58.
(79) Liston C, Chen AC, Zebley BD, et al. Default mode network mechanisms of transcranial magnetic stimulation in depression. Biol Psychiatry 2004; 76, 517-526. https://doi.org/10.1016/j.biopsych.2014.01.023.
(80) Berlim MT, Van Den Eynde F, Daskalakis Z. Clinically meaningful efficacy and acceptability of low-frequency repetitive transcranial magnetic stimulation (rTMS) for treating primary major depression: a meta-analysis of randomized, double-blind and sham-controlled trials. Neuropsychopharmacology 2013; 38, 543-551. https://doi.org/10.1038/npp.2012.237.
(81) Berlim, MT, Van Den Eynde F, Tovar-Perdomo S, Daskalakis ZJ. Response, remission and drop-out rates following high-frequency repetitive transcranial magnetic stimulation (rTMS ) for treating major depression: a systematic review and meta-analysis of randomized , double-blind and sham-controlled trials. Psychol Med.2014; 44, 225-239. https://doi.org/10.1017/S003329171300051.
(82) Brunoni AR, Chaimani A, Moffa AH, et al. Repetitive transcranial magnetic stimulation for the acute treatment of major depressive episodes: a systematic review with network metaanalysis. JAMA Psychiatr 2017; 74,143-153. https://doi.org/10.1001/jamapsychiatry2016.3644.
(83) Cole J, Bright K, Gagnon L, McGirr A. A systematic review of the safety and effectiveness of repetitive transcranial magnetic stimulation in the treatment of peripartum depression. J Psychiatr Res 2019 Aug; 115:142-150. DOI:10.1016/j.jpsychires.2019.05.015. Epub 2019 May 16. Review. PMID:31129438.
(84) Vicario CM, Ali M, Felmingham K, et al. A systematic review on the therapeutic effectiveness of non-invasive brain stimulation for the treatment of anxiety disorders. Neurosci. Biobehav Rev 2019; 96:219-231. https://doi.org/10.1016/j.neubiorev.2018.12.012.
(85) Leach LS, Poyser C, Cooklin AR, Giallo R. Prevalence and course of anxiety disorders (and symptom levels) in men across the perinatal period: A systematic review. J Affect Disord 2016 Jan 15; 190:675-686. DOI:10.1016/j.jad.2015.09.063. Epub 2015 Oct 24. Review. PMID:26590515.
(86) Raglio A, Attardo L, Gontero G, Effects of music and music therapy on mood in neurological patients. World J Psychiatry 2015; 5(1):68-78. https://doi.org/10.5498/wjp.v5.i1.68.
(87) Stegemoller EL Exploring a neuroplasticity model of music therapy. J Music Ther 2014; 51(3):211-227. https://doi.org/10.1093/jmt/thu023.
(88) Salomonsson B. The music of containment: Addressing the participants in mother-infant psychoanalytic treatment. Infant Ment Health J 2011; 32(6):599-612. DOI:10.1002/imhj.20319. Epub 2011 Nov 3. PMID: 28520149.
(89) Guétin S, Portet F, Picot MC, et al. Effect of music therapy on anxiety and depression in patients with Alzheimer's type dementia: randomised, controlled study. Dement Geriatr Cogn Disord 2009; 28(1):36-46. DOI:10.1159/000229024. Epub 2009 Jul 23. PMID:19628939.
(90) Shiranibidabadi S, Mehryar A. Music therapy as an adjunct to standard treatment for obsessive compulsive disorder and co-morbid anxiety and depression: A randomized clinical trial. J Affect Disord 2015 Sep 15; 184:13-7. DOI:10.1016/j.jad.2015.04.011. Epub 2015 Apr 11. Erratum In: J Affect Disord. 2017 Nov; 222:40. PMID: 26066780.
(91) Broder-Fingert S, Feinberg E, Silverstein M. Music therapy for children with autism spectrum disorder. J Am Med Assoc 2017; 318(6):523-524, https://doi.org/10.1001/jama.2017.9477.
(92) Boyde C, Linden U, Boehm K, Ostermann T. The use of music therapy during the treatment of cancer patients: a collection of evidence. Global Advances in Health and Medicine 2012; 1(5): 24-29. https://doi.org/10.7453/gahmj.2012.1.5.009. Epub 2012 Nov 1.
(93) Gutgsell KJ, Schluchter M, Margevicius S, et al. Music therapy reduces pain in palliative care patients: a randomized controlled trial. J Pain Symptom Manage 2013; 45(5):822-31. DOI:10.1016/j.jpainsymman.2012.05.008. Epub 2012 Sep 24. Erratum In: J Pain Symptom Manage 2014 Dec; 48(6):1279. PMID:23017609.
(94) Yang WJ, Bai YM, Qin L, et al. The effectiveness of music therapy for postpartum depression: A systematic review and meta-analysis. Complement Ther Clin Pract 2019; 37:93-101. DOI:10.1016/j.ctcp.2019.09.002. Epub 2019 Sep 16. Review. PMID:31541788.
(95) Scope A, Leaviss J, Kaltenthaler E, Parry G, Sutcliffe P, Bradburn M, Cantrell A. Is group cognitive behaviour therapy for postnatal depression evidence-based practice? A systematic review. BMC Psychiatry 2013 Nov 28; 13:321. DOI:10.1186/1471-244X-13-321.
(96) Grigoriadis S, Ravitz P. An approach to interpersonal psychotherapy for postpartum depression: focusing on interpersonal changes. Can Fam Physician 2007 Sep; 53(9):1469-75. PMID: 17872875.
(97) Curry SJ Krist AH Owens DK, et al. Interventions to prevent perinatal depression: US preventive services task force recommendation statement. JAMA 2019; 321:580-587.
(98) Cluxton-Keller F, Bruce ML. Clinical effectiveness of family therapeutic interventions in the prevention and treatment of perinatal depression: A systematic review and meta-analysis. PLoS One 2018 Jun 14; 13(6):e0198730. DOI:10.1371/journal.pone.0198730. eCollection 2018. PMID:29902211.

This work is licensed under a Creative Commons Attribution 4.0 International License.