New recommendations for screening and treatment of postpartum depression

Perinatal mental health conditions are those that occur during pregnancy and the year after childbirth, whether the onset of the condition(s) predates pregnancy or occurs in the perinatal period. Perinatal mental health conditions are the foremost cause of overall and preventable maternal mortality. It includes a wide array of mental health conditions, including depression, anxiety, and substance use disorders. Perinatal depression affects 1 in 7 perinatal individuals. Although referred commonly to as postpartum depression, more accurately it is called perinatal depression.

Two-thirds of women with perinatal depression have one or more comorbid psychiatric conditions, mainly anxiety disorders (83%), including obsessive-compulsive disorder (11%), social phobia (12%), panic disorder (14%), and generalized anxiety disorder (52%). Untreated perinatal depression is linked with short- and long-term negative consequences for affected individuals and their partners, offspring, society, and families. Perinatal depression remains undertreated and underdetected; more than 75% of those who screen positive receive no treatment. 

Key points:

• In June 2023, the American College of Obstetricians and Gynecologists released new recommendations to minimally screen for depression at least twice in pregnancy (initial prenatal visit and later) and again at postpartum visits, using validated instruments. Additionally, depression screening is recommended at pediatric well-infant/child visits and well-woman visits.
• Before initiating treatment, particularly pharmacotherapy, bipolar disorder must be considered. Up to 1 in 5 persons who screen positive for perinatal depression may have bipolar disorder rather than unipolar depression.
• Psychotherapy is the first-line treatment for mild depression and individuals should be referred for psychotherapy regardless of symptom severity.
• Selective serotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrine reuptake inhibitors (SNRIs) are the most commonly prescribed medications for perinatal depression.
• SSRIs in particular are some of the best-studied medications during pregnancy and are considered reasonable first-line pharmacotherapy during all trimesters and lactation.
• In 2019, a novel treatment for postpartum depression was approved. Brexanolone (Zulresso) is a synthetic neuroactive steroid (allopregnanolone) that is an allosteric modulator of GABAA receptors. It is indicated for individuals with onset of moderate to severe depression in the third trimester or within 4 weeks postpartum.

"Collectively, the effectiveness and impact of perinatal mental health treatments are directly proportional to the ability of perinatal individuals to access them," wrote Tiffany A. Moore Simas, University of Massachusetts Chan Medical School, Worcester, and colleagues. "National and state-based access programs are available to help clinicians address perinatal mental health and increase access to care." 

Reference:

Moore Simas TA, Whelan A, Byatt N. Postpartum Depression—New Screening Recommendations and Treatments. JAMA. Published online November 27, 2023. doi:10.1001/jama.2023.21311