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Treatment Decision Making

Many women with postpartum depression (PPD) face the Treatment Dilemma of whether to pursue pharmacotherapy while breastfeeding.1, 2 Although most women with PPD prefer psychotherapy over pharmacotherapy,3-6 psychotherapy alone may be insufficient for symptom relief for women with more severe PPD.7-9 To resolve this treatment dilemma, the treatment decision making process should be driven by the preferences and needs of client,2, 8 with the rehabilitation counselor providing information and support. The following factors are important to discuss with clients in treatment planning and decision making:

Factors to consider in treatment decision making include: 1. Client treatment preference 2. History of psychiatric treatment 3. Severity 4. risks of treatment 5. risks of untreated postpartum depression 6. Barriers to treatment accessibility  

1. Client Treatment Preference

  • Ask if the client prefers any particular primary treatment strategy.2, 8, 10
    • Due to the benefits of breastfeeding during this period and concerns about breastfeeding while taking antidepressants, most women are reluctant to use antidepressant medications and prefer psychotherapy.3-6
  • Provide information about all treatments that the client expresses interest in.1

2. History of Psychiatric Treatment

  • Ask about previous treatment for depression, and treatment response.8, 10, 11
    • Experts recommend pursuing previously effective treatment first.1, 10, 12, 13

3. Severity, Features, and Duration of Previous Episode(s)

  • Assess severity of PPD.8
    • Greater severity of PPD may indicate need for pharmacological treatment over psychotherapy.1, 7, 11, 14
    • Most guidelines recommend counseling for mild to moderate PPD and antidepressant medication for severe PPD.7, 8, 10, 15  

4. Risks of Treatment

  • Discuss risk of infant adverse effects from transmission of antidepressant medication through breast milk.8, 10, 16, 17
    • All psychotropic medications pass into breast milk and thus present the risk of exposure to breastfeeding infants.10, 12, 18-20
    • Many antidepressants are considered relatively safe for use during breastfeeding, although the long-term effects of antidepressant exposure on infant neurocognitive development are unknown.2, 12, 18, 21  

5. Risks of Untreated Postpartum Depression

  • Discuss risks of untreated postpartum depression,1, 2, 8, 13 which include:
    • Increasing severity of symptoms13 and prolonged duration of the episode.14
    • Detrimental impact on maternal role functioning, including decreased ability to provide for the physical, emotional, and intellectual needs of infant.22-30   
    • Infant is at greater risk of impaired bonding22, 31, 32 and deficits in cognitive,8, 16, 33, 34 behavioral,8, 16, 33, 35 and emotional16, 33, 36 development from continued exposure to maternal depression.

6. Barriers to Treatment Accessibility

  • Discuss any barriers to obtaining or receiving services, and ensure that the client has necessary resources to support her treatment decision.8
  • Potential barriers:
    • Difficulty locating and contacting service providers.5, 6
    • Barriers to accessing services such as transportation difficulties, or not being able to arrange childcare during service receipt.5, 37
  • Solutions to barriers:
    • Provide information about treatment options and referrals to providers in the community.5, 23
    • Provide in vivo services (e.g. home-based, telephone-based).5, 38
      • If services must be office-based, assist client in locating transportation and childcare services offered in the community.39-41


  1. Lanza di Scalea, T., & Wisner, K. L. (2009). Antidepressant medication use during breastfeeding. Clinical Obstetrics & Gynecology, 52(3), 483-497. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=c8h&AN=2010392666&site=ehost-live&scope=site
  2. Pearlstein, T. (2008). Perinatal depression: Treatment options and dilemmas. Journal of Psychiatry & Neuroscience, 33(4), 302-318. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=c8h&AN=2009979613&site=ehost-live&scope=site
  3. Pearlstein, T. B., Zlotnick, C., Battle, C. L., Stuart, S., O’Hara, M. W., Price, A. B., . . . Howard, M. (2006). Patient choice of treatment for postpartum depression: A pilot study. Archives of Women’s Mental Health, 9(6), 303-308. doi: 10.1007/s00737-006-0145-9
  4. Sharp, D. J., Chew-Graham, C. A., Tylee, A., Lewis, G., Howard, L., Anderson, I., . . . Peters, T. J. (2010). A pragmatic randomised controlled trial to compare antidepressants with a community-based psychosocial intervention for the treatment of women with postnatal depression: The RESPOND trial. Health Technology Assessment, 14(43), 1-181. Retrieved from http://www.hta.ac.uk/project/1373.asp
  5. Dennis, C., & Chung-Lee, L. (2006). Postpartum depression help-seeking barriers and maternal treatment preferences: A qualitative systematic review. BIRTH, 33(4), 323-331. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=c8h&AN=2009547198&site=ehost-live&scope=site
  6. Bilszta, J., Ericksen, J., Buist, A., & Milgrom, J. (2010). Women’s experience of postnatal depression: Beliefs and attitudes as barriers to care. Australian Journal of Advanced Nursing, 27(3), 44-54. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=c8h&AN=2010637442&site=ehost-live&scope=site
  7. Altshuler, L. L., Cohen, L. S., Moline, M. L., Kahn, D. A., Carpenter, D., & Docherty, J. P. (2001). The expert consensus guideline series: Treatment of depression in women. Postgraduate Medicine, 1-116. Retrieved from http://www.pmdd.factsforhealth.org/images/depres_in_women_guide.pdf
  8. National Institute for Health and Clinical Excellence. (2007). Antenatal and postnatal mental health: Clinical management and service guidance. Retrieved from http://www.nice.org.uk/nicemedia/live/11004/30433/30433.pdf
  9. Nonacs, R. M. (2005). Postpartum mood disorders. In L. S. Cohen & R. M. Nonacs (Eds.), Mood and anxiety disorders during pregnancy and postpartum (Vol. 24, pp. 77-96). Washington, DC: American Psychiatric Publishing.
  10. Academy of Breastfeeding Medicine, Protocol Committee. (2008). ABM clinical protocol #18: Use of antidepressants in nursing mothers. Breastfeeding Medicine, 3(1), 44-52. doi: 10.1089/bfm.2007.9978 Retrieved from http://www.bfmed.org/Media/Files/Protocols/Protocol_18.pdf
  11. Pearlstein, T., Howard, M., Salisbury, A., & Zlotnick, C. (2009). Postpartum depression. American Journal of Obstetrics & Gynecology, 200(4), 357-364. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=c8h&AN=2010232537&site=ehost-live&scope=site
  12. Ragan K., Stowe Z. N., & Newport J. (2005). Use of antidepressants and mood-stabilizers in breast-feeding women. In L. S. Cohen & R. M. Nonacs (Eds.), Mood and anxiety disorders during pregnancy and postpartum (pp. 105-145). Washington, DC: American Psychiatric Publishing.
  13. Sit, D. K. Y., & Wisner, K. L. (2005). Decision making for postpartum depression treatment. Psychiatric Annals, 35(7), 577-585. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=hch&AN=28025801&site=ehost-live&scope=site
  14. Cohen, L. S., Wang, B., Nonacs, R., Viguera, A. C., Lemon, E. L., & Freeman, M. P. (2010). Treatment of mood disorders during pregnancy and postpartum. Psychiatric Clinics of North America, 33(2), 273-293. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=c8h&AN=2010623522&site=ehost-live&scope=site
  15. Registered Nurses’ Association of Ontario (2005). Nursing best practice guideline: Interventions for postpartum depression. Retrieved from http://www.rnao.org/Storage/11/600_BPG_Post_Partum_Depression.pdf
  16. Scottish Intercollegiate Guidelines Network. (2002). Postnatal depression and puerperal psychosis: A national clinical guideline. Retrieved from http://www.sign.ac.uk/pdf/sign60.pdf
  17. Neiman, S., Carter, S., Van Sell, S., & Kindred, C. (2010). Best practice guidelines for the nurse practitioner regarding screening, prevention, and management of postpartum depression. Critical Care Nursing Quarterly, 33(3), 212-218. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=c8h&AN=2010713332&site=ehost-live&scope=site
  18. Berle, J. Ø., & Spigset, O. (2008). Maternal antidepressant use and breastfeeding. Current Medical Literature: Psychiatry, 19(2), 33-37. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=aph&AN=32583099&site=ehost-live&scope=site
  19. Kendall-Tackett, K., & Hale, T. W. (2010). The use of antidepressants in pregnant and breastfeeding women: A review of recent studies. Journal of Human Lactation, 26(2), 187-195. doi: 10.1177/0890334409342071
  20. Fortinguerra, F., Clavenna, A., & Bonati, M. (2009). Psychotropic drug use during breastfeeding: A review of the evidence Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=aph&AN=45351861&site=ehost-live&scope=site
  21. Hallberg, P., & Sjoblom, V. (2005). The use of selective serotonin reuptake inhibitors during pregnancy and breast-feeding: A review and clinical aspects. Journal of Clinical Psychopharmacology, 25(1), 59-73. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=lhh&AN=20053042422&site=ehost-live&scope=site; http://www.psychopharmacology.com/pt/re/jclnpsychopharm/abstract.00004714-200502000-00010.htm;jsessionid=C2vM8fh1sOcCbo09roOHFKn86e7Po4AxvTuZrvjLK1YykKkwximY!1578349637!-949856031!9001!-1
  22. American Psychiatric Association. (2010). Practice guidelines for the treatment of major depressive disorder (3rd ed.). doi: 10.1176/appi.books.9780890423387.654001
  23. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. (2010). Clinical report: Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. doi: 10.1542/peds.2010-2348
  24. Logsdon, M. C., Wisner, K. L., & Pinto-Foltz, M. (2006). The impact of postpartum depression on mothering. Journal of Obstetric, Gynecologic & Neonatal Nursing, 35(5), 652-658. Retrieved from https://auth.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=2009291246&site=ehost-live&scope=site
  25. Field, T. (2010). Postpartum depression effects on early interactions, parenting, and safety practices: A review. Infant Behavior and Development, 33(1), 1-6. doi: 10.1016/j.infbeh.2009.10.005
  26. McLearn, K. T., Minkovitz, C. S., Strobino, D. M., Marks, E., & Hou, W. (2006). Maternal depressive symptoms at 2 to 4 months postpartum and early parenting practices. Archives of Pediatrics & Adolescent Medicine, 160(3), 279-284. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=c8h&AN=2009330888&site=ehost-live&scope=site
  27. Paulson, J. F., Dauber, S., & Leiferman, J. A. (2006). Individual and combined effects of postpartum depression in mothers and fathers on parenting behavior. Pediatrics, 118(2), 659-668. doi: 10.1542/peds.2005-2948
  28. Zajicek-Farber, M. L. (2009). Postnatal depression and infant health practices among high-risk women. Journal of Child and Family Studies, 18, 236–245. doi: 10.1007/s10826-008-9224-z
  29. Minkovitz, C. S., Strobino, D., Scharfstein, D., Hou, W., Miller, T., Mistry, K. B., & Swartz, K. (2005). Maternal depressive symptoms and children’s receipt of health care in the first 3 years of life. Pediatrics, 115(2), 306-314. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=c8h&AN=2005091432&site=ehost-live&scope=site
  30. Lovejoy, M. C., Graczyk, P. A., O’Hare, E., & Neuman, G. (2000). Maternal depression and parenting behavior: A meta-analytic review. Clinical Psychology Review, 20(5), 561-592. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=flh&AN=FLH3778232535&site=ehost-live&scope=site
  31. Martins, C., & Gaffan, E. A. (2000). Effects of early maternal depression on patterns of infant-mother attachment: A meta-analytic investigation. Journal of Child Psychology & Psychiatry & Allied Disciplines, 41(6), 737. Retrieved from https://auth.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=3673783&site=ehost-live&scope=site
  32. Coyl, D. D., Roggman, L. A., & Newland, L. A. (2002). Stress, maternal depression, and negative mother–infant interactions in relation to infant attachment. Infant Mental Health Journal, 23(1), 145-163. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=aph&AN=11772372&site=ehost-live&scope=site
  33. Hay, D. F., Pawlby, S., Waters, C. S., & Sharp, D. (2008). Antepartum and postpartum exposure to maternal depression: Different effects on different adolescent outcomes. Journal of Child Psychology and Psychiatry, 49(10), 1079-1088. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=eric&AN=EJ814291&site=ehost-live&scope=site; http://dx.doi.org.libproxy.lib.unc.edu/10.1111/j.1469-7610.2008.01959.x
  34. Murray, L., Arteche, A., Fearon, P., Halligan, S., Croudace, T., & Cooper, P. (2010). The effects of maternal postnatal depression and child sex on academic performance at age 16 years: A developmental approach. Journal of Child Psychology & Psychiatry, 51(10), 1150-1159. doi:10.1111/j.1469-7610.2010.02259.x
  35. Josefsson, A., & Sydsjö, G. (2007). A follow-up study of postpartum depressed women: Recurrent maternal depressive symptoms and child behavior after four years. Archives of Women’s Mental Health, 10(4), 141-145. doi: 10.1007/s00737-007-0185-9
  36. Halligan, S. L., Murray, L., Martins, C., & Cooper, P. J. (2007). Maternal depression and psychiatric outcomes in adolescent offspring: A 13-year longitudinal study. Journal of Affective Disorders, 97(1-3), 145-154. doi: 10.1016/j.jad.2006.06.010
  37. Nylen, K. J., Segre, L. S., & O’Hara, M. W. (2005). Public health implications of postpartum depression. Psychiatric Annals, 35(7), 599-609. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=hch&AN=28025804&site=ehost-live&scope=site
  38. Letourneau, N., Duffett-Leger, L., Stewart, M., Hegadoren, K., Dennis, C., Rinaldi, C. M., & Stoppard, J. (2007). Canadian mothers’ perceived support needs during postpartum depression. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 36(5), 441-449. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=psyh&AN=2007-14061-005&site=ehost-live&scope=site
  39. Mowbray, C. T., Oyserman, D., Bybee, D., MacFarlane, P., & Rueda-Riedle, A. (2001). Life circumstances of mothers with serious mental illness. Psychiatric Rehabilitation Journal, 25(2), 114-123. Retrieved from https://auth.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2001-10143-002&site=ehost-live&scope=site
  40. Nicholson, J., & Henry, A. D. (2003). Achieving the goal of evidence-based psychiatric rehabilitation practices for mother with mental illnesses. Psychiatric Rehabilitation Journal, 27(2), 122-130. Retrieved from https://auth.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=11531676&site=ehost-live&scope=site
  41. Diaz-Caneja, A., & Johnson, S. (2004). The views and experiences of severely mentally ill mothers: A qualitative study. Social Psychiatry & Psychiatric Epidemiology, 39(6), 472-482. Retrieved from https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=aph&AN=13461320&site=ehost-live&scope=site

Last Updated July 19, 2011