The management of perinatal depression is similar to depression at other stages of life, but with the additional considerations
of the pregnancy, the fetus or infant and the mother-infant relationship:5, 8, 21
Management is also guided by the relative success of any previous treatments and the patient’s preference. Reassurance
is an important component of management to negate any feelings of failure or weakness. The approach to treatment is similar
for women with anxiety, with non-pharmacological strategies used first. In women with concurrent moderate to severe depression
and anxiety, medicines prescribed to treat the depression are often effective in reducing anxiety.8
Non-pharmacological interventions are recommended for all patients with depression or anxiety
Non-pharmacological interventions are the first-line treatment for depression or anxiety. These focus on promoting a
healthy lifestyle with adequate nutrition, exercise and sleep and providing psychoeducation, i.e. information and problem-solving
techniques, developing coping strategies, building resilience against relapses and establishing social supports. The patient’s
thoughts and concerns should be explored to identify contributing factors, e.g. a perceived failure to meet expectations,
problems with the physical limitations of pregnancy and childbirth, financial concerns or social isolation.22 If
there are financial or accommodation stressors it may be helpful to provide a letter of support to a relevant agency.
Support groups can be valuable as they help to connect people with similar experiences and facilitate socialising, e.g.
antenatal group meetings or Parents Centre groups (see: “Resource for patients”).
Encourage engagement with friends and family
Behavioural activation, e.g. re-engaging with enjoyable activities and the support of family/whānau/friends, should
be encouraged. In general, recommend face-to-face contact with friends and family and that social isolation be avoided.
Social media may exacerbate unrealistic expectations of motherhood and it may be appropriate to recommend that some patients
minimise their contact with these platforms.
Cognitive behavioural therapy is the most effective perinatal psychological intervention
Cognitive behaviour therapy (CBT) is a form of psychotherapy that helps people understand their response to challenging
circumstances, thereby enabling them to improve their management of the situation. Online CBT is available (see: “Resources
for patients”). Patients may also be referred to counselling (depending on local availability) or pay for private
sessions with a clinical psychologist. CBT is associated with significant improvements in the symptoms of postnatal depression
over the short and long-term.23
Several other psychological therapies may also be used to manage perinatal depression and anxiety, although they are
less commonly available than CBT. Interpersonal therapy (IPT) focuses on resolving relationship problems and is an effective
intervention for depression during pregnancy, although in general it appears to be less effective than CBT.24 Acceptance
and Commitment Therapy (ACT) utilises mindfulness and focuses patients on values, forgiveness, acceptance and compassion.
Several trials are currently assessing the effectiveness of ACT in treating perinatal mood disorders.
The pharmacological management of perinatal depression
The indications for the pharmacological treatment of perinatal depression are the same as for depression occurring at
other stages, i.e. moderate to severe depression or persistent mild to moderate depression that has not responded to non-pharmacological
Women can be reassured that the benefits of appropriately prescribed antidepressants generally outweigh the risks.1,
7 If a woman already taking an antidepressant becomes pregnant it is recommended that she continue taking the same
medicine (see: “Withdrawing antidepressants during pregnancy is not recommended”).7
The potential for an antidepressant to cause adverse effects in the fetus or breastfeeding infant is influenced by a
number of factors, including:7
- The timing of exposure during pregnancy
- The individual risks associated with the specific antidepressant
- The infant dose received while breastfeeding
The differences in the relative safety between antidepressants is, however, not considered to be sufficient to outweigh
the potential risks of switching antidepressants in women who are already receiving effective treatment.7 Breast
feeding is encouraged regardless of the antidepressant that is being taken.1
SSRIs are often the preferred antidepressants during the perinatal period
SSRIs have been extensively studied during the perinatal period and are generally the preferred class of antidepressant
during this time on the basis of safety and efficacy (see: “The risks of taking SSRIs during the perinatal
period”).7 SSRIs are also generally the first-line antidepressant for depression occurring at other stages
of life, therefore continuity of pharmacological treatment may be a consideration for some patients.
Sertraline, citalopram and escitalopram are the first-choice SSRIs
Sertraline is often preferred for women with perinatal depression as it has the lowest infant exposure during breast
feeding.1, 7 There is also evidence suggesting that sertraline is the SSRI associated with the lowest risk
of persistent pulmonary hypertension (PPHT).25 Citalopram and escitalopram are also reasonable choices during
the perinatal period on the basis of safety and efficacy.1, 26
Paroxetine has low to undetectable serum levels in breastfed infants, however, an increased risk of congenital cardiac
defects and neonatal behavioural syndrome following in utero exposure means that another SSRI would generally be preferred.7,
26 Fluoxetine is the least preferred SSRI during breastfeeding, as its long half-life increases exposure in breastfed
Prescribe the same SSRI if previous treatment has been successful
For women with a history of successful treatment with a SSRI, it is recommended that clinicians offer the same medicine,
unless there are compelling reasons to recommend an alternative.7 When discussing options with the patient,
the rationale is that it is preferable to prescribe a medicine that is known to be tolerated and effective for an individual,
even if there is research suggesting the risks may be lower in an alternative medicine.7
Prescribe the lowest effective dose
Treatment with an SSRI should begin at the lower end of the therapeutic dose range, e.g. 50 mg of sertraline daily,27 and
then slowly titrated upwards, if necessary, until the woman feels that her symptoms are manageable. It is important to
be mindful of the risks of under-dosing which may expose the woman and fetus to adverse effects without treating the depression
adequately.5 It may be necessary to increase the dose of the antidepressant during the third trimester to account
for changes in metabolism or haemodilution if clinical monitoring indicates that depressive symptoms are returning. If
the woman’s symptoms are well-controlled the previous dosing regimen can be reinstated in the weeks following childbirth.
The optimal duration of treatment is unknown
There is no specific guidance for the duration of antidepressant treatment for perinatal depression.5 A similar
duration of treatment for depression occurring at other stages of life is therefore recommended, i.e. for at least one
year following a single episode of depression and at least three years for recurrent episodes.8 Earlier withdrawal
of an antidepressant may be considered for patients who have responded well to treatment. The PHQ-9 questionnaire can
be used to assess treatment response and guide treatment decisions.
Second-line options if SSRIs are ineffective or not tolerated
Tricyclic antidepressants (TCAs) are generally considered to be safe during pregnancy and breastfeeding and are associated
with a similar risk of fetal and infant adverse effects as SSRIs.7 TCAs are, however a second-line option as
they may cause maternal adverse effects such as sedation and are more likely to be fatal in overdose.26
Venlafaxine may be a treatment option for women who have not responded to an SSRI, however, due to an increased risk
of neonatal withdrawal (including seizures), venlafaxine is only considered if safer treatment options have not been successful.26,
Antidepressants should be withdrawn gradually
If an antidepressant is withdrawn, this should be done slowly with the woman monitored closely for symptoms of relapse
and SSRI discontinuation reactions, and where appropriate other health professionals involved in her care informed.7 It
may also be necessary to intensify non-pharmacological treatment.
Further information on the use of antidepressants for the treatment of depression is available from: “The
role of medicines for the management of depression primary care”
Arrange a follow-up within the next two weeks
Active follow-up is recommended for all patients who present with mental health issues, e.g. negotiate a review plan
involving a phone call from the practice after 24–48 hours, a follow-up appointment in one or two weeks and where appropriate
passing on any relevant information to her LMC.28 If the patient does not attend the follow-up appointment,
they should be contacted to check on their well-being.5
Encourage the patient to bring her partner or other family member to the next consultation as their support is important
and they may provide insights into her condition. The partner should also feel supported by the primary care team and
know who to contact if they have concerns.
For further information on identifying and managing perinatal depression, see the Goodfellow Unit webinar presented by Dr Mark Huthwaite: