May 24, 2021
Mental Health Awareness Month
Treatment Options in Postpartum Depression: A Research Review
By A. Brenda Wafo, MD, MPH
Editor’s Note: During Mental Health Awareness Month, we have published about the relationship between stress and premenstrual syndrome (PMS), the impact of estrogen and progesterone on the brain, and how charting the menstrual cycle serves as a tool for mental health. This week, Dr. Brenda Wafo reviews a 2009 research article[i] by di Scalea and Wisner titled, “Pharmacotherapy of Postpartum Depression.” The authors reviewed twelve articles on treatment and seven articles on prevention of postpartum depression. Their findings are summarized below, and the topic is discussed in the context of clinical practice.
A Personal Introduction
Over the years, I have listened to many women tell their stories about the postpartum period and how challenging it was. Although a decent number of these women suffered from postpartum depression, I have not heard this topic addressed enough. This needs to change, given that, as of the 2009 article by di Scalea and Wisner, the prevalence of postpartum depression was 13% with a recurrence rate of 25% with future pregnancies. Recent data from CDC research[ii] published in 2020 still reports a 13% prevalence of postpartum depression, with only 1 in 8 women with postpartum depression being asked about symptoms of depression during postpartum visits.
Generally, physicians have monthly follow-up visits with women during the antepartum period to optimize their prenatal care. Patients who are considered “high risk” have even more frequent visits. When it comes to the intrapartum period, it is “all hands on deck.” I have witnessed physicians work so hard, and go above and beyond to ensure women have successful deliveries—from uncomplicated spontaneous vaginal deliveries to emergency cesarean sections. Yet, as soon as the baby is born and the mother is medically stable, much of that attention seems to fade away. Women who have vaginal deliveries often have only one postpartum visit.
It is interesting how much time and effort medical professionals devote to the antepartum and intrapartum periods compared to the postpartum period, which is a significant transition for every woman. This transition may lead to considerable challenges that can impact women physically, financially, and mentally. This period presents with many stressors, and the natural decrease in progesterone causes hormonal shifts that can have additional effects on a mother’s mood.
A clinical guidance reaffirmed by the American College of Obstetricians and Gynecologists (ACOG) in 2021 addresses appropriate care in the postpartum period. The document states, “To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs. Indeed, in qualitative studies, women have noted that there is an intense focus on women’s health prenatally but care during the postpartum period is infrequent and late.”[iii]
In the article, “Pharmacotherapy for Postpartum Depression,” di Scalea and Wisner review the literature on the use of antidepressants and hormonal therapy (estrogen and progesterone) to prevent and treat postpartum depression. A search using PubMed, Medline, and PsychINFO was conducted with the following inclusion criteria: empirical articles in peer-reviewed English language journals, well validated measures of depression, and uniform scoring system for depression among the sample. Through this search, 19 articles were found, 12 of which addressed treatment of postpartum depression, with 7 articles exploring prevention of postpartum depression. Out of the 19 articles, 8 were randomized clinical trials while 11 were open label studies.
Prevention of postpartum depression
Regarding prevention of the recurrence of postpartum depression, the only serotonin reuptake inhibitor (SSRI) that was found to be efficacious in a randomized controlled trial was sertraline. Estrogen and progesterone were also found to be efficacious in open label studies. According to the data, these therapies are to be started at the onset of the postpartum period in women with past history of postpartum depression.
Treatment of postpartum depression
Regarding the treatment of postpartum depression, therapies found to be efficacious included antidepressants such as sertraline, venlafaxine, and paroxetine, as well as hormonal therapy such as transdermal estradiol.Some of the studies showed that hormonal therapy can help with both prevention and treatment of postpartum depression.
The treatment of postpartum depression often revolves around antidepressants, both in clinical training and in practice. This was also the case during most of my training, until I observed a patient visit during the FACTS elective in which progesterone was discussed as a treatment option for postpartum depression. It is known that progesterone decreases after pregnancy and that hormonal changes can affect a woman’s mood, so why not address the root of the problem by helping balance out these hormones?
More research needs to be done about this important topic. The article summarized here about pharmacotherapy of postpartum depression was published in 2009, and most of the studies reviewed had small sample sizes and were conducted prior to the year 2000. Since then, there has been more development. Slowly, more people are learning about fertility awareness-based methods (FABMs). This leads to more people understanding the effects of hormonal changes during the menstrual cycle, pregnancy, the postpartum period, perimenopause, menopause, and various medical conditions in greater depth. The more these methods are taught, the more this information will spread among colleagues and faculty. This way, more people may take the initiative to conduct larger studies surrounding these topics, including using hormonal therapy for postpartum depression. With newer and larger studies, medical professionals will hopefully feel more comfortable using these therapies as they care for women.
Editor’s Note: Dr. Thomas Hilgers, creator of the Creighton Model and Natural Procreative Technology (NaPro), developed a protocol for the management of postpartum depression with the use of progesterone.His studies show a significant and almost immediate decrease in symptoms with intramuscular injection of progesterone. Recent studies suggest that progesterone may increase concentrations of allopregnanolone in the central nervous system, which has been shown to relieve symptoms of postpartum depression. Although more research needs to be done, progesterone may also prove to be an effective, easy-to-administer treatment for postpartum depression.
[i] di Scalea TL, Wisner KL. Pharmacotherapy of postpartum depression. Expert Opin Pharmacother. 2009;10(16):2593-2607. doi:10.1517/14656560903277202.
[ii] Bauman BL, Ko JY, Cox S, et al. Vital Signs: Postpartum Depressive Symptoms and Provider Discussions About Perinatal Depression — United States, 2018. MMWR Morb Mortal Wkly Rep 2020;69:575–581. DOI: http://dx.doi.org/10.15585/mmwr.mm6919a2.
[iii] Optimizing Postpartum Care. ACOG. (2016, June). https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care.
About the Author
Brenda Wafo, MD
Brenda Wafo, MD aspired to be a physician from an early age due to the lack of access to health resources and education she witnessed growing up in Cameroon, Africa. She achieved her dream of becoming a physician and is completing the last year of family medicine residency. Because of her strong passion for community and women’s health, she was excited to learn in great detail about fertility-based awareness methods through FACTS. Hence, she became a FACTS ambassador and took the FACTS elective, both of which have been fulfilling and inspiring. With this knowledge, she hopes to continue to educate and empower her community.
The FACTS CME Course
Coming in Early June!
The FACTS 4-part CME Course – Fertility Awareness Based Methods (FABMs) for Family Planning and Restorative Reproductive Women’s Healthcare prepares you as a medical professional to present more comprehensive options for family planning and women’s health monitoring and management of a range of reproductive health concerns. Through online lectures, live case study discussions, and readings, this course will explore the broad applications of modern Fertility Awareness-Based Methods (FABMs) and their role in pregnancy prevention, infertility, and women’s health.
The course is divided into four parts; you may elect to do any or all of them and they may be completed in any order. Each part is worth up to 14 AAFP-approved CME credits.
In Part A, An Introduction to Modern FABMs for Family Planning, participants will survey modern evidence-based FABMs, including the research underlying the development of the different methods, their effectiveness rates to prevent pregnancy, and the benefits and challenges of using each method. Participants may engage in live case-based discussions to learn how to read the charts of various FABMs.
In Part B, Special Topics in FABMs for Helping Couples Achieve or Avoid Pregnancy, participants can further their knowledge on the subject of fertility awareness and its applications in family planning. Part B will focus on the role of FABMs to address infertility and early pregnancy loss, and on the availability of apps marketed to help people avoid pregnancy. Learners may participate in case-based discussions that explore the medical applications of FABMs, including their role in addressing infertility and other conditions.
In Part C, FABMs for Restorative Reproductive Medicine and at Various Stages of Life, participants will learn how internal hormone shifts result in observable external signs, or biomarkers, that women can learn to use to chart their cycles and monitor their health. Participants will learn how medical professionals trained in restorative reproductive medicine can use this information to care for women in a more comprehensive way. We will also discuss how FABMs can be used throughout a woman’s reproductive life, from adolescence and the postpartum period to perimenopause.
In Part D, Medical Applications of FABMs, participants will connect the science of endocrinology to core concepts of FABMs, which may be used to diagnose and manage common women’s health conditions, including abnormal uterine bleeding, endometriosis, polycystic ovarian syndrome (PCOS), and premenstrual syndrome (PMS). They will learn how FABMs are used to monitor women’s health and facilitate the diagnosis and treatment of various women’s medical conditions, and how these methods empower a woman to understand her body and physiology better.