The patient is diagnosed with major depressive disorder and begins weekly psychotherapy. Arrangements are made to have extra help in the home. Despite these interventions, she becomes increasingly depressed and anxious. The patient's husband is concerned that she is getting worse. He says, "Although the baby is healthy, she continues to worry about the baby's feeding and growth and berates herself for being a bad mother. She even has difficulty making everyday decisions such as what diapers and groceries to buy." The patient has difficulty falling and staying asleep. Her appetite is poor, and she has lost 15 pounds over the past month. She says, "Maybe my baby would be better off without me" but has no intention or plan to take her own life or hurt her baby. No delusions or hallucinations are elicited. The patient is willing to take medication but wants to continue breastfeeding and does not want to take anything that would harm the baby. Which of the following is the most appropriate intervention?

Question

The patient is diagnosed with major depressive disorder and begins weekly psychotherapy.  Arrangements are made to have extra help in the home.  Despite these interventions, she becomes increasingly depressed and anxious.  The patient's husband is concerned that she is getting worse.  He says, "Although the baby is healthy, she continues to worry about the baby's feeding and growth and berates herself for being a bad mother.  She even has difficulty making everyday decisions such as what diapers and groceries to buy."  The patient has difficulty falling and staying asleep.  Her appetite is poor, and she has lost 15 pounds over the past month.  She says, "Maybe my baby would be better off without me" but has no intention or plan to take her own life or hurt her baby.  No delusions or hallucinations are elicited.  The patient is willing to take medication but wants to continue breastfeeding and does not want to take anything that would harm the baby.  Which of the following is the most appropriate intervention?

Quizplus · Accepted Answer

Explanation: Antidepressant therapy is indicated as this patient's depression is not responding to psychotherapy alone. Although all antidepressants are secreted in breast milk, research shows that the risk to infants from most antidepressants is low, and mothers should not be discouraged from breastfeeding (Choice E). Selective serotonin reuptake inhibitors (SSRIs) are the most widely studied class of antidepressants, with the best safety data for the drugs sertraline and paroxetine. The amount of these drugs secreted in breast milk is negligible and may be lower compared to other SSRIs and other classes of antidepressants. Sertraline and paroxetine are therefore considered first-line choices for postpartum, lactating patients who are starting treatment with an antidepressant. Patients who were treated with antidepressants during pregnancy up until delivery should be maintained on the same medication that was prescribed before delivery. (Choice A) Bupropion is generally not recommended as an initial choice in lactating women because there is less evidence for the safety of infant exposure to bupropion through breast milk, and a case report shows a possible association between infant exposure and seizures. (Choice B) Electroconvulsive therapy is considered a safe treatment option in the perinatal period; however, it is typically reserved for patients with treatment-resistant depression. (Choice D) This patient can be treated on an outpatient basis as she has no suicidal intent or plan and has adequate support. In addition, hospitalization could interfere with her ability to bond with the infant and develop a sense of competence as a mother. Patients with suicidal intent or plan, thoughts of harming the infant, or psychosis should be hospitalized. Educational objective: Patients with postpartum depression can be treated with antidepressants and continue breastfeeding. Sertraline and paroxetine are first-line drugs as they have the best safety record, and amounts secreted into breast milk are low or undetectable. References: Sertraline and breastfeeding: review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25589155) Serotonin reuptake inhibitors and breastfeeding: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/25572308)

The Patient Is Diagnosed with Major Depressive Disorder and Begins