Pharmacotherapy of postpartum depression

The development of a patient decision aid to reduce decisional conflict about antidepressant use in pregnancy

Background

People with moderate to severe depression in pregnancy must weigh potential risks of untreated or incompletely treated depression against the small, but uncertain risks of fetal antidepressant drug exposure. Clinical support alone appears insufficient for helping individuals with this complex decision. A patient decision aid (PDA) has the potential to be a useful tool for this population. The objective of our work was to use internationally recognized guidelines from the International Patient Decision Aids Standards Collaboration to develop an evidence-based PDA for antidepressant use in pregnancy.

Methods

A three-phased development process was used whereby, informed by patient and physician perspectives and evidence synthesis, a steering committee commissioned a web-based PDA for those deciding whether or not to start or continue antidepressant treatment for depression in pregnancy (Phase 1). A prototype was developed (Phase 2) and iteratively revised based on feedback during field testing based on a user-centred process (Phase 3).

Results

We developed a web-based PDA for people deciding whether to start or continue antidepressant use for depression in pregnancy. It has five interactive sections: (1) information on depression and treatment; (2) reasons to start/continue an antidepressant and to start/stop antidepressant medication; (3) user assessment of values regarding each issue; (4) opportunity to reflect on factors that contribute to decision making; and (5) a printable PDF that summarizes the user’s journey through the PDA.

Conclusions

This tool, which exclusively focuses on depression treatment with Selective Serotonin Reuptake Inhibitors and Serotonin–Norepinephrine Reuptake Inhibitors, can be used by individuals making decisions about antidepressant use to treat depression during pregnancy. Limitations of the PDA are that it is not for other conditions, nor other medications that can be used for depression, and in its pilot form cannot be used by women who do not speak English or who have a visual impairment. Pending further study, it has the potential to enhance quality of care and patient experience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01870-1.

Preventing Postpartum Depression With Mindful Self-Compassion Intervention: A Randomized Control Study

Mindfulness and self-compassion are reported to have a preventive effects on depression and anxiety disorders. In the present study, we aimed to assess the effect of mindful self-compassion intervention on preventing postpartum depression in a group of symptomatic pregnant women. Participants were screened and assigned to the intervention and control groups randomly. A 6-week Internet-based Mindful Self-Compassion Program was used to train the participants. Multiple scales were used to assess depressive and anxiety symptoms, mindfulness, self-compassion, and mother and infant well-being. All assessments were performed at three time points: baseline, 3 months, and 1 year postpartum. Compared with the control group, the intervention group showed significant improvement in depressive and anxiety behaviors. In addition, the intervention group became more mindful and self-compassionate at 3 months and 1 year postpartum. More importantly, both mothers and infants experienced substantial improvement in well-being. Our findings indicate that mindful self-compassion intervention is effective in preventing postpartum depression and promoting mother and infant well-being.

A patient decision aid for antidepressant use in pregnancy: study protocol for a randomized controlled trial

Background

Many women with depression experience significant difficulty making a decision about whether or not to use antidepressant medication in pregnancy. Patient decision aids (PDAs) are tools that assist patients in making complex health decisions. PDAs can reduce decision-making difficulty and lead to better treatment outcomes. We describe the methods for a pilot randomized controlled trial of an interactive web-based PDA for women who are having difficulty deciding about antidepressant drug use in pregnancy.

Methods/Design

This is a pilot randomized controlled trial that aims to assess the feasibility of a larger, multi-center efficacy study. The PDA aims to help a woman: (1) understand why an antidepressant is being recommended, (2) be knowledgeable about potential benefits and risks of treatment and non-treatment with antidepressants, and (3) be clear about which benefits and risks are most important to her, with the goal of improving confidence in her decision-making. We include women aged 18 years or older who are: (1) planning a pregnancy or are pregnant (gestational age less than 30 weeks), (2) diagnosed with major depressive disorder, (3) deciding whether or not to use a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI) antidepressant in pregnancy, and (4) having at least moderate decision-making difficulty as per a Decisional Conflict Scale (DCS) Score ≥25. Participants are randomized to receive the PDA or an informational resource sheet via a secure website, and have access to the stated allocation until their final study follow-up. The primary outcomes of the pilot study are feasibility of recruitment and retention, acceptability of the intervention, and adherence to the trial protocol. The primary efficacy outcome is DCS score at 4 weeks post randomization, with secondary outcomes including depressive and anxiety symptoms.

Discussion

Our PDA represents a key opportunity to optimize the decision-making process for women around antidepressants in pregnancy, leading to effective decision-making and optimizing improved maternal and child outcomes related to depression in pregnancy. The electronic nature of the PDA will facilitate keeping it up-to-date, and allow for widespread dissemination after efficacy is demonstrated.

Trial registration

This trial is registered on ClinicalTrials.Gov under the identifier NCT02308592 (first registered: 2 December 2014).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1233-4) contains supplementary material, which is available to authorized users.

Quality assessment of observational studies in psychiatry: an example from perinatal psychiatric research

In perinatal psychiatry, randomized controlled trials are often not feasible on ethical grounds. Many studies are observational in nature, while others employ large databases not designed primarily for research purposes. Quality assessment of the resulting research is complicated by a lack of standardized tools specifically for this purpose. The aim of this paper is to describe the Systematic Assessment of Quality in Observational Research (SAQOR), a quality assessment tool our team devised for a series of systematic reviews and meta-analyses of evidence-based literature regarding risks and benefits of antidepressant medication during pregnancy.

Differentiation and clinical implications of postpartum depression and postpartum psychosis

Postpartum depression and postpartum psychosis are serious mood disorders encountered by nurses working in a variety of settings. Postpartum depression refers to a nonpsychotic depressive episode, while postpartum psychosis refers to a manic or affective psychotic episode linked temporally with childbirth. The nursing profession plays a crucial role in the early identification and treatment of these postpartum mood disorders. This article explains the classification, clinical presentation, epidemiology, management, and long-term outcomes of postpartum depression and postpartum psychosis.

Use of psychotropic medications in treating mood disorders during lactation : practical recommendations

Many new mothers who need antidepressant or mood-stabilising drug treatment may wish to breastfeed their infants, but are hesitant to do so because of possible harmful effects of the medication on the infant. This article reviews current data on drug excretion into breast milk and the effects on the breast-fed child, and provides recommendations for the use of the different psychotropic drugs in lactating women. Relevant literature was identified through systematic searches of MEDLINE, EMBASE and the Science Citation Index Expanded (ISI) from 1966 to February 2005. The present knowledge is based on the accumulation of case studies. No randomised controlled trials in breast-fed infants have been performed and there is a lack of long-term follow-up studies. Use of SSRIs and TCAs (except doxepin) is compatible with breastfeeding. However, if treatment with an SSRI is started in the postpartum period, fluoxetine and citalopram may not be drugs of first choice. With regard to other antidepressants, such as venlafaxine, trazodone, mirtazapine, reboxetine, moclobemide and other MAOIs, very little knowledge exists. Breastfeeding should be avoided while using lithium. Carbamazepine and sodium valproate (valproic acid) are generally better tolerated by the breast-fed infant than lithium. Data on lamotrigine are still sparse. Knowledge is also scarce on the novel antipsychotics and thus recommendations in lactating women cannot be made for these agents. It is unwise to expose infants unnecessarily to drugs that may have severe adverse effects. As such, clozapine should probably be avoided because of the risk of agranulocytosis. Our knowledge of the impact of drug exposure through breast milk is still limited. Infant drug exposure is, however, generally higher during pregnancy through placental passage than through breast milk. Despite the low dosage transferred to the infant through breast milk, premature infants and infants with neonatal diseases or inherited disturbances in metabolism may be vulnerable to such exposure.

Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies

Since the previous publication of Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines in 1997, there has been a substantial increase in evidence-based treatment options for bipolar disorder. The present guidelines review the new evidence and use criteria to rate strength of evidence and incorporate effectiveness, safety, and tolerability data to determine global clinical recommendations for treatment of various phases of bipolar disorder. The guidelines suggest that although pharmacotherapy forms the cornerstone of management, utilization of adjunctive psychosocial treatments and incorporation of chronic disease management model involving a healthcare team are required in providing optimal management for patients with bipolar disorder. Lithium, valproate and several atypical antipsychotics are first-line treatments for acute mania. Bipolar depression and mixed states are frequently associated with suicidal acts; therefore assessment for suicide should always be an integral part of managing any bipolar patient. Lithium, lamotrigine or various combinations of antidepressant and mood-stabilizing agents are first-line treatments for bipolar depression. First-line options in the maintenance treatment of bipolar disorder are lithium, lamotrigine, valproate and olanzapine. Historical and symptom profiles help with treatment selection. With the growing recognition of bipolar II disorders, it is anticipated that a larger body of evidence will become available to guide treatment of this common and disabling condition. These guidelines also discuss issues related to bipolar disorder in women and those with comorbidity and include a section on safety and monitoring.

The role of estrogen therapy in postpartum psychiatric disorders: an update

OBJECTIVES

The aim of this review is to assess and summarize the existing literature data about the efficacy of estrogen replacement therapy (ERT) in preventing and treating postpartum psychiatric disorders.

METHODS

An extensive and unrestrictive computerized search (from 1970 to June 2005) on MEDLINE/PubMed, TOXNET, EMBASE, and Cochrane Databases was conducted with the following search terms: estradiol, estrogen-treatment, hormonal treatment, therapy, postpartum depression, postnatal depression, puerperal depression, postpartum blues, postpartum psychosis, lactation, and breastfeeding.

RESULTS

In assessing available literature information about the role of ERT in preventing and treating puerperal psychiatric diseases, all reviewed studies were found to suffer from severe methodological limitations.

CONCLUSION

Well-designed and strictly focused multicenter trials are warranted in order to firmly establish the effectiveness of ERT in puerperal psychiatric disorders.

Identifying and Treating Postpartum Depression

Postpartum depression affects 10% to 20% of women in the United States and negatively influences maternal, infant, and family health. Assessment of risk factors and depression symptoms is needed to identify women at risk for postpartum depression for early referral and treatment. Individual and group psychotherapy have demonstrated efficacy as treatments, and some complementary/alternative therapies show promise. Treatment considerations include severity of depression, whether a mother is breastfeeding, and mother's preference. Nurses who work with childbearing women can advise depressed mothers regarding treatment options, make appropriate recommendations, provide timely and accessible referrals, and encourage engagement in treatment.