Postpartum depression (PPD) is a serious illness that rarely gets better on its own. It requires treatment, and the good news is that good treatment is available. The specific treatment you receive depends on the severity of your symptoms.
For instance, according to the Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines, and UpToDate.com, the first-line treatment for mild to moderate symptoms of postpartum depression is psychotherapy—namely cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). The second-line treatment is medication—namely certain selective serotonin reuptake inhibitors (SSRIs).
For severe symptoms of PPD, the first-line treatment is medication. Often, a combination of medication and psychotherapy is best.
Therapy can be incredibly helpful for treating postpartum depression (PPD). The two main therapies that appear to be effective are cognitive behavioral therapy (CBT) and interpersonal therapy (IPT), both of which are time limited (around 12 to 20 weeks).
CBT is based on the idea that our thoughts and behaviors are linked to our mood. CBT focuses on helping moms identify their problematic thoughts, challenge them, and change them into supportive, healthy beliefs. It also helps moms develop healthy coping strategies, relaxation techniques, and problem solving skills.
Traditionally, CBT is conducted in person either individually or in a group setting. Some preliminary research suggests that telephone-based CBT can be helpful, particularly for mild to moderate symptoms of PPD. Other research also suggests that therapist-assisted internet-delivered CBT decreases symptoms of PPD, reduces anxiety and stress, and increases quality of life.
IPT focuses on improving your relationships and circumstances that are directly related to your depression. You and your therapist will pick one interpersonal problem area to work on (there are four in total): role transition, role disputes, grief, or interpersonal deficits. IPT has been specifically tailored to moms to address your relationship with your baby, your relationship with your partner, and your transition back to work (if relevant). You’ll also learn communication skills.
Other treatments that may be helpful include: behavioral activation, nondirective counseling, psychodynamic psychotherapy, mindfulness-based CBT, supportive therapy, and couples therapy. For instance, behavioral activation helps you engage in enjoyable activities, reduce rumination and avoidance behaviors, and sharpen your problem-solving skills. Psychodynamic therapy explores how our earliest experiences directly shape our present problems and influence our perceptions of ourselves. It helps you gain a deeper awareness into your thoughts, feelings, and experiences, and resolve and change current issues.
Before prescribing any medication, it’s very important for your doctor to screen for any history of mania or hypomania to rule out bipolar disorder. For instance, one study found that 50 percent of women with bipolar II disorder also reported PPD. Being properly diagnosed, of course, is critical for effective treatment. When medications for depression are prescribed by themselves, they can trigger a manic or hypomanic episode.
Medication is typically prescribed for women with moderate to severe symptoms of postpartum depression (PPD). The biggest concern new moms have about taking medicine is how it’ll affect their baby if they breastfeed. In general, the benefits of taking medication for PPD far outweigh the risks.
Research has found a variety of short- and long-term negative consequences associated with PPD when it goes untreated, such as insecure attachment and cognitive, behavioral, and emotional problems. Also, if left untreated, PPD can get worse. That is, possible complications include suicidal ideation and behavior, psychotic or catatonic symptoms, and substance abuse.
If your depression started during pregnancy, and you’ve been taking medication that’s been effective for you, you’ll likely continue taking the same dose. Similarly, if you’ve ever taken an antidepressant that worked in treating a previous bout of depression, your doctor will probably prescribe it again.
Overall, selective serotonin reuptake inhibitors (SSRIs) are widely prescribed for PPD, and are the treatment of choice for the condition. SSRIs do pass through breast milk, but it’s a minimal amount. Long-term studies on the effects of SSRIs on infants and kids have not been done. However, experts agree that women taking SSRIs should not be discouraged from breastfeeding—if that’s something they’d like to do. The benefits of breastfeeding tend to outweigh the risks of antidepressants. (And, of course, it’s perfectly OK to give your baby formula.)
Your doctor will likely begin with the lowest effective dose. If necessary, they’ll slowly increase the dose until it successfully reduces your symptoms (with minimal side effects) through a process called “titration.”
Several sources differ on which SSRIs to prescribe to moms who are taking antidepressants for the first time. For instance, UpToDate.com and The New England Journal of Medicine suggest starting with sertraline (Zoloft), paroxetine (Paxil), or citalopram (Celexa) because of their safety records. The New England Journal of Medicine also adds fluoxetine (Prozac) as a first-line option.
However, the 2016 guidelines from the Canadian Network for Mood and Anxiety Treatments (CANMAT) note that fluoxetine and paroxetine should be used as second-line treatments—“the former because of its long half-life and slightly higher rates of minor adverse reactions in breastfed infants, and the latter because of its association with CV malformations in subsequent pregnancies.” CANMAT also states that escitalopram (Lexapro) should be a first-line option.
So, which is it? The takeaway is that it’s best to have a thoughtful, thorough discussion with your doctor, because what all sources do agree on is that one size doesn’t fit all. In other words, decisions around medication should be made on an individual basis.
The side effects of SSRIs include: nausea or vomiting; dizziness; trouble sleeping; sexual dysfunction (such as decreased sex drive and delayed orgasm); headaches; diarrhea; and dry mouth. Some of these side effects are short term, while others might last (such as sexual problems).
When SSRIs don’t work, the next step is to try a serotonin and norepinephrine reuptake inhibitor (SNRIs). Research has found that venlafaxine (Effexor) effectively reduces symptoms of depression and anxiety. This is especially important because many, if not most, women with PPD experience significant anxiety, as well.
Monoamine oxidase inhibitors (MAOIs), another class of antidepressants, are rarely prescribed because of their potential adverse effects and unknown safety during breastfeeding.
The tricyclic antidepressant doxepin (Silenor) should be avoided because of reports of infant respiratory depression, poor sucking, and vomiting. However, the tricyclic antidepressant nortriptyline (Pamelor) has solid evidence of safety for breastfeeding moms. Side effects include increased heart rate, drowsiness, dizziness, dry mouth, constipation, weight gain or loss, sexual problems, blurred vision, and trouble urinating.
If your anxiety is especially severe, your doctor might prescribe a benzodiazepine along with an antidepressant. UpToDate.com suggests starting with the lowest effective dose that has a short half-life and no active metabolites, such as lorazepam (Ativan). They also suggest prescribing the medication for no longer than 2 weeks.
In some cases, if women with severe symptoms have a partial response to their antidepressant, a doctor might prescribe another medication to augment or boost the effects, such as lithium or an antipsychotic. The antipsychotics haloperidol (Haldol), quetiapine (Seroquel), and risperidone (Risperdal) appear to be compatible with breastfeeding, while lurasidone has limited evidence in lactating women, and clozapine may trigger side effects in infants, such as hematologic toxicity and seizures.
Several sources suggested taking your medication right after nursing to reduce exposure to the baby. However, according to another source, there’s little evidence that this is helpful. When sources contradict each other, again, it’s important to ask your doctor.
In general, when meeting with your doctor, make sure to speak up about any concerns you have about taking medication. Ask about potential side effects. Ask how long you might be taking the medication. Ask what kinds of benefits you can expect—and when. With most medications, it’ll take about 4 to 8 weeks to feel the full effects.
Also, if you decide to take an antidepressant, it’s important for your pediatrician to establish a baseline of your baby’s health, and regularly monitor them—monthly, for instance—for adverse effects, such as irritability, excessive crying, poor weight gain, or sleep problems. If there seems to be an issue, reduce or stop breastfeeding to make it easier to tell whether your medications are the cause.
In March 2019, the U.S. Food and Drug Administration (FDA) approved the first drug developed specifically for treating postpartum depression. The drug, brexanolone (Zulresso), is a continuous IV infusion that is administered over 60 hours at a certified healthcare facility by a healthcare provider. It provides immediate relief from depressive symptoms. Women receiving the injection must be carefully monitored because of potential serious risks, such as excessive sedation and sudden loss of consciousness. Before insurance, the drug is estimated to cost $30,000.
Brexanolone might be an option when a woman has severe PPD and other antidepressants haven’t worked. (It is not a first-line treatment.)
Another option when multiple antidepressants haven’t worked and symptoms are severe is electroconvulsive therapy (ECT). According to UpToDate.com, observational data suggest that ECT is beneficial for PPD and safe for breastfeeding moms. ECT does come with several immediate side effects, such as confusion, nausea, headache, and muscle aches. It also commonly causes memory loss, so that you have trouble remembering things that happened right before treatment or in the weeks or months before treatment. As with other interventions, the decision to have ECT should be made thoughtfully and collaboratively with your doctor (whenever possible).
Sage Therapeutics, the biopharmaceutical company that produces brexanolone, is currently conducting trials testing SAGE-217, a pill that seems promising in rapidly reducing depressive symptoms.
- Seek out reputable resources. The non-profit organization Postpartum Support International offers a number you can call (1-800-944-4773) to speak with a volunteer coordinator to learn about resources in your area, such as finding a psychiatrist or therapist. You also can click on their U.S. map (or list of other countries) to find a name, number, and email address to directly contact (unfortunately, not all locations have coordinators, but you can still call the 800 number). LactMed is a peer-reviewed database from the National Institutes of Health that features information on different drugs and their possible adverse effects in a nursing infant.
- Prioritize sleep. We tend to minimize the power of sleep for our mental, emotional, and physical health. But sleep is medicine, and critical for your recovery. Trying to get sleep when you have a newborn (and possibly other kids) might seem impossible—and like very annoying advice. However, again, think of this as a non-negotiable medical necessity, as sleep deprivation exacerbates depression. Enlist your loved ones in helping you identify practical solutions. If you’re breastfeeding, try to pump during the day, so your partner (or someone else) can feed the baby while you get a long stretch of uninterrupted sleep. If pumping isn’t possible, consider giving your baby formula at night. Ask friends to come over, and watch your baby, so you can sleep. Establish a nightly shift schedule with your spouse—even if you’re on maternity leave or a stay-at-home mom. When your baby is old enough, consider sleep training (or hiring a sleep trainer).
- Find support. Ask your therapist about local support groups you could join. Also, Postpartum Support International has online support groups and a closed, private Facebook group. You also might find it helpful to join moms’ groups.
- Get help with daily chores. Make a list of everything that needs to get done on a regular basis, such as laundry, cooking, sweeping, mopping, cleaning the bathrooms, and grocery shopping. Ask loved ones to pick something from the list that they can do. If it’s in your budget, hire help, such as a housecleaning or laundry service. (If it’s not in your budget, maybe you can skimp somewhere else.)
- Take regular walks. If you’re physically ready, take walks with your baby, so you can both enjoy the fresh air (weather permitting). If you’re ready for more vigorous exercise, try to add that to your weekly routine, as well. Even 5 to 10 minutes can boost your mood and relieve your stress.
- Find small ways to strengthen your bond. Whether you’re nursing or not, try to incorporate more skin-to-skin contact with your baby throughout the day. Giving your baby a 10- or 15-minute massage also is helpful—and giving the massage before bedtime might even lead to better sleep.
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