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psych.postpartum-depression.v1PRODUCTION
psych.postpartum-depression.v1

Postpartum depression — perinatal MDD (ACOG 757 2018/2024; USPSTF 2019; NICE NG192 2024; APA 2010 PPD; Meltzer-Brody 2018; Deligiannidis 2023)

psychiatrysubacutechronicadultpregnancy
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Postpartum (within 12 months; symptom-onset peak 4–6 wk) patient with depressive symptoms WITHOUT psychotic features — confirm DSM-5-TR peripartum specifier; objective is severity tiering + lactation-aware regimen + suicide screen + bipolar screen + medical differential + cross-route if psychotic / suicidal / bipolar (ACOG 757 2018/2024; USPSTF 2019; APA 2010 PPD)

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Postpartum context confirmed and depressive symptoms documented

Patient inputs (25)

Adolescent + advanced-maternal-age modifiers; baseline pharmacokinetic considerations (APA 2010 PPD; PSI 2024)

Drives SSRI / neurosteroid selection (sertraline / paroxetine first-line in lactation per LactMed 2024 + PSI 2024 + APA 2010 PPD; brexanolone REMS infusion + zuranolone CYP3A4 + driving advisory)

Mood Disorder Questionnaire — bipolar screen MANDATORY before SSRI initiation; cutoff ≥ 7 LR+ ~ 4 for bipolar spectrum; PPD often first presentation of bipolar in women (Hirschfeld AJP 2000 PMID 11058486; STEP-BD Sachs NEJM 2007 PMID 17392295)

Sleep deprivation is a baseline postpartum feature; characterise sleep duration / quality / opportunity-vs-inability; sleep < 4 h × 2 d in known bipolar postpartum is a red flag for impending postpartum psychosis (Bergink 2012; APA 2010 PPD)

Prior PPD ~ 35–50% recurrence; prior MDD ~ 25–30% recurrence in subsequent pregnancy / postpartum (Wisner 2013 PMID 23446353; Stewart NEJM 2016 PMID 27959687)

Family history of bipolar disorder or postpartum psychosis loads bipolar-screen probability; family history of MDD loads recurrence risk (Hirschfeld 2000 PMID 11058486; APA 2024)

Mother-infant interaction assessment — PPD associated with infant cognitive + emotional impact (Murray Br J Psychiatry 1996; PSI 2024)

Perinatal alcohol / opioid / stimulant / cannabis use complicates PPD presentation and treatment (SAMHSA TIP 51 2018; ACOG 757 2018/2024)

Identify current antidepressant, mood stabiliser, antipsychotic, contraception; review for offending agents and pregnancy-class issues (APA 2010 PPD; NICE NG192 2024)

Onset window — DSM-5-TR peripartum specifier within 12 months postpartum; symptom-onset peak 4–6 wk postpartum (Stewart NEJM 2016 PMID 27959687; ACOG 757 2018/2024)

Postpartum thyroiditis (5–10% of postpartum women) — thyrotoxic phase 1–4 mo can mimic mania or anxiety; hypothyroid phase 4–8 mo can mimic / worsen depression (ATA 2017 Alexander Thyroid 2017 PMID 28056690)

Postpartum anemia (Hgb) — can cause / worsen fatigue + low mood; iron deficiency common postpartum (ACOG 757 2018/2024)

Columbia Suicide Severity Rating Scale — postpartum SI carries elevated lethality; suicide leading cause of maternal mortality through 1 y postpartum (Posner 2011 PMID 22193671; Trost MMWR 2022 PMID 35587456)

Explicit ask: "Have you had any thoughts of harming yourself or your baby?" — never assume safety based on outward presentation (PSI 2024; ACOG 757 2018/2024)

Edinburgh Postnatal Depression Scale — 10-item self-report; cutoff ≥ 10 or ≥ 13; primary screening tool perinatal (Cox 1987 PMID 3651732; Levis 2020 PMID 33208495; ACOG 757 2018/2024)

PHQ-9 alternative perinatal screening tool — cutoff ≥ 10 with item-9 SI flag (Kroenke JGIM 2001 PMID 11556941; ACOG 757 2018/2024)

Functional impact (self-care / infant-care / household / work / relationships) drives severity tiering independently of EPDS / PHQ-9 score (APA 2010 PPD; NICE NG192 2024)

Sheehan syndrome (postpartum hypopituitarism) screen if hypotension / lactation failure / persistent fatigue / AMS — rare but high-stakes miss (Endocrine Society 2016)

GAD-7 — postpartum anxiety frequently comorbid with PPD (~ 17% in postpartum women); informs treatment intensity (Spitzer 2006; ACOG 757 2018/2024)

Partner / paternal PPD ~ 10% in fathers; partner EPDS ≥ 10 → partner referral; family-system approach (Paulson JAMA 2010 PMID 20483968; PSI 2024)

B12 / folate deficiency differential for depressive symptoms (APA 2010 PPD)

Baseline electrolytes + glucose + calcium — rule out metabolic mimics (APA 2010 PPD; NICE NG192 2024)

Baseline for SSRI hepatotoxicity monitoring; zuranolone is CYP3A4 metabolised (APA 2010 PPD; FDA Zurzuvae 2023)

Baseline creatinine + eGFR for any renal-cleared adjunct (lithium if bipolar emergence) (APA 2024; KDIGO 2024)

Substance-induced mood disorder differential; perinatal substance use screen (SAMHSA TIP 51 2018; ACOG 757 2018/2024)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningppd_with_si_or_infant_harm_ideation
    Active suicidal ideation with plan / intent / means OR recent suicide attempt OR thoughts of harming infant in postpartum patient with depressive symptoms — life-threatening; suicide is a leading cause of maternal mortality through 1 year postpartum (Trost MMWR 2022 PMID 35587456; Posner 2011 PMID 22193671; ACOG 757 2018/2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningppd_with_psychotic_features
    Hallucinations, delusions, or grossly disorganised thought / behaviour emerging in a postpartum patient with depressive symptoms — re-evaluate for postpartum psychosis; routes to psych.postpartum-psychosis.v1 (ACOG 757 2018/2024; APA 2010 PPD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_ppd_brexanolone_or_zuranolone_eligible
    EPDS ≥ 20 + functional impact + (adequate SSRI trial failed at 4–6 wk OR rapid relief needed OR severe presentation) — eligible for brexanolone IV 60-h infusion at REMS-accredited site OR zuranolone 50 mg PO daily × 14 days outpatient (Meltzer-Brody Lancet 2018 PMID 30253856; Deligiannidis AJP 2023 PMID 37467049; APA 2010 PPD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebipolar_emergence_with_ppd_treatment
    Manic / hypomanic features (decreased need for sleep / pressured speech / racing thoughts / grandiosity / risk-taking) emerging on SSRI initiation OR positive MDQ at baseline (≥ 7) — DISCONTINUE SSRI + add mood stabiliser; routes to psych.bipolar-disorder.core.v1 (STEP-BD Sachs NEJM 2007 PMID 17392295; APA 2024; Hirschfeld AJP 2000 PMID 11058486)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatebreastfeeding_medication_selection_critical
    PPD patient actively breastfeeding requiring pharmacotherapy — informed-consent discussion + LactMed-guided choice; sertraline / paroxetine first-line (low M/P ratio + low infant exposure); citalopram / escitalopram / venlafaxine / nortriptyline / bupropion acceptable; fluoxetine cautioned (long half-life + high M/P ratio though not contraindicated) (LactMed 2024; PSI 2024; APA 2010 PPD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateinfant_attachment_disturbance_emerging
    Infant feeding / sleep / development concerns + maternal lack of engagement / bonding disturbance — mother-infant dyadic therapy + family support + perinatal social work (PSI 2024; Murray Br J Psychiatry 1996)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpostpartum_thyroiditis_overlap
    Depressive symptoms with onset 3–6 mo postpartum + fatigue + cold-intolerance OR thyrotoxic symptoms in 1–4 mo phase — postpartum thyroiditis differential (5–10% of postpartum women; thyrotoxic phase 1–4 mo then hypothyroid phase 4–8 mo per ATA 2017 Alexander Thyroid 2017 PMID 28056690)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpaternal_partner_ppd_screening_positive
    Partner EPDS ≥ 10 OR partner self-report depressive symptoms — partner referral; family-system approach (Paulson JAMA 2010 PMID 20483968; PSI 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

First-line PPD pharmacotherapy + psychotherapy for mild-to-moderate PPD (APA 2010 PPD; ACOG 757 2018/2024; USPSTF 2019 Curry JAMA PMID 30747971; NICE NG192 2024)
axis: postpartum_depression_first_linestep 1 - Step 1 — Psychotherapy first-line for mild PPD (EPDS 10–12 + no functional impact) (USPSTF 2019 PMID 30747971; Cuijpers meta-analyses; APA 2010 PPD; NICE NG192 2024)
Selected step "Step 1 — Psychotherapy first-line for mild PPD (EPDS 10–12 + no functional impact) (USPSTF 2019 PMID 30747971; Cuijpers meta-analyses; APA 2010 PPD; NICE NG192 2024)" — Mild PPD with EPDS 10–12 and no significant functional impact and no SI; or moderate-severe PPD as adjunct to SSRI (APA 2010 PPD)
  • cognitive behavioural therapy (CBT)
    first line
    psychotherapy
    12–16 weekly sessions • in_person_or_telehealth • weekly
    triggers: mild_to_moderate_PPD, patient_preference_for_psychotherapy, breastfeeding_with_pharm_concerns
    CBT first-line for mild-to-moderate PPD; Cuijpers meta-analyses + USPSTF 2019 B-grade recommendation; no infant exposure issue (USPSTF 2019 PMID 30747971; APA 2010 PPD; NICE NG192 2024)
  • interpersonal therapy (IPT)
    first line
    psychotherapy
    12–16 weekly sessions • in_person_or_telehealth • weekly
    triggers: mild_to_moderate_PPD, role_transition_focus, partner_or_paternal_PPD_overlap
    IPT specifically designed for role-transition and interpersonal-conflict context — high resonance with perinatal life events; USPSTF 2019 B-grade (USPSTF 2019 PMID 30747971; APA 2010 PPD)

outpatient playbook — drug actions (5)

  1. 1. CBT or IPT referral first-line for mild PPD (EPDS 10–12 + no functional impact)
    12–16 weekly sessions • in_person_or_telehealth • weekly
    trigger: Mild PPD with EPDS 10–12 and no significant functional impact and no SI (USPSTF 2019 PMID 30747971; APA 2010 PPD)
    Psychotherapy first-line in mild-to-moderate PPD; no infant exposure; USPSTF B-grade (USPSTF 2019 PMID 30747971; APA 2010 PPD; NICE NG192 2024)
  2. 2. sertraline 50 mg PO daily, titrate to 100–200 mg/day (first-line SSRI in lactation)
    50 mg PO daily titrate to 100–200 mg/day • PO • once daily
    trigger: Moderate PPD (EPDS 13–19) OR functional impact OR no response to psychotherapy at 4 wk OR comorbid GAD-7 ≥ 10 (APA 2010 PPD)
    First-line SSRI in breastfeeding per LactMed 2024 + PSI 2024 + APA 2010 PPD — low M/P ratio + low infant exposure (LactMed 2024; PSI 2024; APA 2010 PPD)
  3. 3. paroxetine 10–50 mg PO daily as alternative first-line SSRI in lactation
    10 mg PO daily titrate to 20–50 mg/day • PO • once daily
    trigger: Moderate PPD + lactation + sertraline tolerability issue + no planned next pregnancy (paroxetine pregnancy category D)
    First-line SSRI in breastfeeding per LactMed 2024; avoid in NEXT pregnancy (FDA 2015) (LactMed 2024; APA 2010 PPD)
  4. 4. consider zuranolone 50 mg PO daily × 14 days (Zurzuvae) for severe PPD (EPDS ≥ 20) outpatient-feasible
    50 mg PO daily × 14 days • PO • once daily × 14 days
    trigger: Severe PPD (EPDS ≥ 20 + functional impact) + outpatient feasible + patient prefers oral over IV brexanolone (Deligiannidis AJP 2023 PMID 37467049; FDA Zurzuvae 2023)
    First oral neurosteroid PPD-specific therapy; 14-day course; outpatient-feasible; CYP3A4 metabolised; CNS-depressant + driving advisory (FDA Zurzuvae 2023; Deligiannidis 2023)
  5. 5. refer for brexanolone IV 60-h infusion at REMS-accredited site for severe PPD requiring inpatient or accredited-outpatient infusion
    IV 60-h continuous infusion per FDA Zulresso REMS protocol • IV • 60-h single course
    trigger: Severe PPD (EPDS ≥ 20 + functional impact) + access to REMS site + patient consent + cannot wait 14 days for zuranolone (FDA Zulresso REMS 2019; Meltzer-Brody Lancet 2018 PMID 30253856)
    FDA-approved 2019 for moderate-severe PPD; REMS-supervised infusion required due to sedation/syncope risk; rapid onset (~ 60 h) (Meltzer-Brody 2018; FDA Zulresso REMS 2019)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Depressed mood, anhedonia, fatigue, guilt, sleep / appetite disturbance, decreased concentration within 12 months postpartum (DSM-5-TR peripartum specifier; ACOG 757 2018/2024); EPDS ≥ 10 or ≥ 13 OR PHQ-9 ≥ 10 at routine perinatal screening visit (ACOG 757 2018/2024; USPSTF 2019 Curry JAMA PMID 30747971; Cox 1987 PMID 3651732; Levis 2020 PMID 33208495); Suicidal ideation, thoughts of self-harm, or thoughts of harming infant in postpartum patient — emergency C-SSRS + safety triage (Posner 2011 PMID 22193671; Trost MMWR 2022 PMID 35587456).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Postpartum depression — perinatal MDD (ACOG 757 2018/2024; USPSTF 2019; NICE NG192 2024; APA 2010 PPD; Meltzer-Brody 2018; Deligiannidis 2023)** (psych.postpartum-depression.v1).
Phenotype framing: Postpartum depression (primary perinatal MDD) vs postpartum psychosis (psychotic features → route to psych.postpartum-psychosis.v1) vs bipolar I/II depressive episode (MDQ ≥ 7 → route to psych.bipolar-disorder.core.v1) vs adjustment disorder vs postpartum thyroiditis (TSH abnormal) vs postpartum anemia / B12 deficiency vs Sheehan syndrome vs substance-induced mood disorder vs paternal / partner PPD overlap (DSM-5-TR 2022; ACOG 757 2018/2024; APA 2010 PPD)
Scope: Postpartum (within 12 months; symptom-onset peak 4–6 wk) patient with depressive symptoms WITHOUT psychotic features — confirm DSM-5-TR peripartum specifier; objective is severity tiering + lactation-aware regimen + suicide screen + bipolar screen + medical differential + cross-route if psychotic / suicidal / bipolar (ACOG 757 2018/2024; USPSTF 2019; APA 2010 PPD)

No severity triggers fired against current inputs.

Plan

Regimen axis: **First-line PPD pharmacotherapy + psychotherapy for mild-to-moderate PPD (APA 2010 PPD; ACOG 757 2018/2024; USPSTF 2019 Curry JAMA PMID 30747971; NICE NG192 2024)** — step "Step 1 — Psychotherapy first-line for mild PPD (EPDS 10–12 + no functional impact) (USPSTF 2019 PMID 30747971; Cuijpers meta-analyses; APA 2010 PPD; NICE NG192 2024)".
1. cognitive behavioural therapy (CBT) 12–16 weekly sessions in_person_or_telehealth weekly (psychotherapy, first line) — CBT first-line for mild-to-moderate PPD; Cuijpers meta-analyses + USPSTF 2019 B-grade recommendation; no infant exposure issue (USPSTF 2019 PMID 30747971; APA 2010 PPD; NICE NG192 2024)
2. interpersonal therapy (IPT) 12–16 weekly sessions in_person_or_telehealth weekly (psychotherapy, first line) — IPT specifically designed for role-transition and interpersonal-conflict context — high resonance with perinatal life events; USPSTF 2019 B-grade (USPSTF 2019 PMID 30747971; APA 2010 PPD)

Setting playbook (outpatient) — Universal EPDS / PHQ-9 screening at intake + 24–28 wk gestation + delivery + 6-wk postpartum + 1/2/4/6-mo well-child visits; severity tiering; lactation-aware SSRI selection (sertraline / paroxetine first-line); CBT / IPT first-line for mild-moderate; perinatal psych Q2 wk × 12 wk then monthly × 12 mo; C-SSRS at every visit; partner / paternal PPD screening; mother-infant attachment + bonding assessment; preconception counselling for next pregnancy (ACOG 757 2018/2024; USPSTF 2019 PMID 30747971; APA 2010 PPD; NICE NG192 2024; PSI 2024)
3. CBT or IPT referral first-line for mild PPD (EPDS 10–12 + no functional impact) 12–16 weekly sessions in_person_or_telehealth weekly — Mild PPD with EPDS 10–12 and no significant functional impact and no SI (USPSTF 2019 PMID 30747971; APA 2010 PPD) (Psychotherapy first-line in mild-to-moderate PPD; no infant exposure; USPSTF B-grade (USPSTF 2019 PMID 30747971; APA 2010 PPD; NICE NG192 2024))
4. sertraline 50 mg PO daily, titrate to 100–200 mg/day (first-line SSRI in lactation) 50 mg PO daily titrate to 100–200 mg/day PO once daily — Moderate PPD (EPDS 13–19) OR functional impact OR no response to psychotherapy at 4 wk OR comorbid GAD-7 ≥ 10 (APA 2010 PPD) (First-line SSRI in breastfeeding per LactMed 2024 + PSI 2024 + APA 2010 PPD — low M/P ratio + low infant exposure (LactMed 2024; PSI 2024; APA 2010 PPD))
5. paroxetine 10–50 mg PO daily as alternative first-line SSRI in lactation 10 mg PO daily titrate to 20–50 mg/day PO once daily — Moderate PPD + lactation + sertraline tolerability issue + no planned next pregnancy (paroxetine pregnancy category D) (First-line SSRI in breastfeeding per LactMed 2024; avoid in NEXT pregnancy (FDA 2015) (LactMed 2024; APA 2010 PPD))
6. consider zuranolone 50 mg PO daily × 14 days (Zurzuvae) for severe PPD (EPDS ≥ 20) outpatient-feasible 50 mg PO daily × 14 days PO once daily × 14 days — Severe PPD (EPDS ≥ 20 + functional impact) + outpatient feasible + patient prefers oral over IV brexanolone (Deligiannidis AJP 2023 PMID 37467049; FDA Zurzuvae 2023) (First oral neurosteroid PPD-specific therapy; 14-day course; outpatient-feasible; CYP3A4 metabolised; CNS-depressant + driving advisory (FDA Zurzuvae 2023; Deligiannidis 2023))
7. refer for brexanolone IV 60-h infusion at REMS-accredited site for severe PPD requiring inpatient or accredited-outpatient infusion IV 60-h continuous infusion per FDA Zulresso REMS protocol IV 60-h single course — Severe PPD (EPDS ≥ 20 + functional impact) + access to REMS site + patient consent + cannot wait 14 days for zuranolone (FDA Zulresso REMS 2019; Meltzer-Brody Lancet 2018 PMID 30253856) (FDA-approved 2019 for moderate-severe PPD; REMS-supervised infusion required due to sedation/syncope risk; rapid onset (~ 60 h) (Meltzer-Brody 2018; FDA Zulresso REMS 2019))

Non-pharmacologic actions:
- Universal EPDS / PHQ-9 screening at every prenatal + postpartum visit + well-child visits per ACOG 757 2018/2024 cadence
- Stanley-Brown Safety Planning Intervention if any positive C-SSRS — completed BEFORE end of visit (Stanley-Brown 2012 PMID 22642958)
- Lethal-means restriction counselling at every visit — firearm + large-quantity medications (VA/DoD 2019)
- Perinatal psychiatry referral for moderate-severe PPD (EPDS ≥ 13 OR functional impact OR comorbid anxiety / substance use / bipolar-screen-positive) (APA 2010 PPD)
- Psychotherapy referral (CBT / IPT — in-person or telehealth) for mild-moderate PPD (USPSTF 2019; APA 2010 PPD; NICE NG192 2024)
- Partner / paternal PPD screening at family / dyad visits — partner referral if EPDS ≥ 10 (Paulson JAMA 2010 PMID 20483968)
- Mother-infant dyadic therapy referral if attachment disturbance emerging (PSI 2024)
- Pediatric coordination — infant pediatrician dosed-in on maternal medication plan if breastfeeding on SSRI (PSI 2024)
- OB postpartum check coordination — 1-wk + 6-wk visits with shared psychiatric / obstetric communication (ACOG 757 2018/2024)
- 988 Suicide & Crisis Lifeline + Postpartum Support International 1-800-944-4773 reinforced at every visit (SAMHSA TIP 50 2015; PSI 2024)
- Preconception counselling for women of reproductive age — explicit discussion of ~ 35–50% recurrence rate in next pregnancy + risk-benefit of antidepressant continuation through pregnancy + paroxetine avoidance in next pregnancy (Wisner 2013; APA 2010 PPD)
- Family / partner psychoeducation — recognition of warning signs (worsening mood, sleep < 4 h × 2 nights, intrusive thoughts, manic features) (NICE NG192 2024; PSI 2024)
- Sleep hygiene + structured infant-care plan to maximise maternal sleep opportunity (APA 2010 PPD)
- Mother-baby support group referral (Postpartum Support International, MotherToBaby) (PSI 2024)
- Lactation consultation if breastfeeding + on SSRI / neurosteroid (LactMed 2024; PSI 2024)

AVOID / contraindication checks:
- Do_NOT_start_SSRI_without_bipolar_screen_MDQ_or_manic_history_ask (STEP BD Sachs NEJM 2007 PMID 17392295; APA 2024)
- Do_NOT_default_to_discontinuing_antidepressant_during_pregnancy_or_postpartum_without_psychiatric_consult (ACOG 757 2018/2024; APA 2010 PPD)
- Do_NOT_prescribe_fluoxetine_first_line_in_actively_breastfeeding_if_alternative_available (LactMed 2024; PSI 2024)
- Paroxetine_pregnancy_category_D_cardiovascular_malformations_AVOID_in_NEXT_pregnancy (FDA 2015; APA 2010 PPD)
- Citalopram_QTc_max_40mg_FDA_2011 (FDA 2011)
- Bupropion_AVOID_in_seizure_or_eating_disorder (FDA)
- SSRI_serotonin_syndrome_risk_with_linezolid_MAOI_triptan (APA 2010 PPD)

Monitoring

Regimen monitoring:
- EPDS at every visit during first 12mo postpartum (ACOG 757 2018/2024)
- PHQ-9 at every visit (Kroenke 2001; ACOG 757 2018/2024)
- C-SSRS at every visit (Posner 2011; Trost MMWR 2022)
- MDQ at baseline before SSRI initiation then re screen if manic features emerge (Hirschfeld 2000; APA 2024)
- SSRI response at 4 and 6 wk (APA 2010 PPD)
- Bipolar emergence surveillance manic features on SSRI (STEP-BD Sachs 2007; APA 2024)
- Infant sedation feeding weight gain at pediatric visits on maternal SSRI (LactMed 2024; PSI 2024)
- Functional impact at every visit (APA 2010 PPD; NICE NG192 2024)

Setting (outpatient) monitoring:
- EPDS / PHQ-9 / C-SSRS at every visit (ACOG 757 2018/2024; Posner 2011)
- SSRI response at 4 and 6 wk (APA 2010 PPD)
- Bipolar emergence surveillance — manic features on SSRI = STOP SSRI + route to psych.bipolar-disorder.core.v1 (STEP-BD Sachs 2007; APA 2024)
- Functional impact at every visit (APA 2010 PPD)
- Infant sedation / feeding / weight gain at pediatric visits on maternal SSRI (LactMed 2024; PSI 2024)
- Mother-infant attachment + bonding (PSI 2024; Murray 1996)
- Partner / paternal PPD re-screen (Paulson 2010)
- Postpartum thyroiditis re-evaluation Q3 mo for first year if initial TSH abnormal (ATA 2017 Alexander Thyroid 2017 PMID 28056690)
- Substance use re-screen at every visit (SAMHSA TIP 51 2018)

Follow-up plan: Perinatal psychiatry Q2 wk × 12 wk then monthly × 12 mo postpartum; OB postpartum follow-up coordinated; pediatric coordination if breastfeeding on psychotropics (infant pediatrician dosed-in); mother-infant dyadic therapy if attachment disturbance; partner / paternal PPD referral if screening positive; SSRI maintenance ≥ 6–12 months after remission per APA 2010 PPD; preconception counselling for next pregnancy — recurrence ~ 35–50%; Caring Contacts cascade if prior SI episode (Motto 2001 PMID 11433109; Stanley/Brown 2018 PMID 30209345; APA 2010 PPD; PSI 2024)
- Close-out criterion: Outpatient bridge + perinatal psych + OB + peds coordination in place; family-system referrals made when indicated

Monitoring phase: EPDS + PHQ-9 + C-SSRS at every visit; SSRI titration response at 4–6 weeks; bipolar-emergence surveillance (manic features on SSRI = STOP + route to bipolar); brexanolone REMS sedation/syncope monitoring during infusion; zuranolone CNS-depressant + driving advisory + 14-day course completion; lactation pharmacology monitoring (infant for sedation / feeding / weight gain); infant attachment + development tracking; partner / paternal PPD re-screen; postpartum thyroiditis follow-up (ACOG 757 2018/2024; APA 2010 PPD; LactMed 2024; PSI 2024)

Disposition

Current setting: outpatient — Universal EPDS / PHQ-9 screening at intake + 24–28 wk gestation + delivery + 6-wk postpartum + 1/2/4/6-mo well-child visits; severity tiering; lactation-aware SSRI selection (sertraline / paroxetine first-line); CBT / IPT first-line for mild-moderate; perinatal psych Q2 wk × 12 wk then monthly × 12 mo; C-SSRS at every visit; partner / paternal PPD screening; mother-infant attachment + bonding assessment; preconception counselling for next pregnancy (ACOG 757 2018/2024; USPSTF 2019 PMID 30747971; APA 2010 PPD; NICE NG192 2024; PSI 2024)

Disposition criteria:
- Continued outpatient perinatal psychiatry indefinitely during first 12 months postpartum with bridge to PCP / general psychiatry thereafter if recurrent MDD risk (APA 2010 PPD)
- Step-up to ED / admit consideration if SI plan/intent OR severe functional collapse OR brexanolone REMS infusion needed (Trost MMWR 2022; FDA Zulresso REMS 2019)
- Re-route to psych.postpartum-psychosis.v1 if psychotic features emerge (ACOG 757 2018/2024)
- Re-route to psych.bipolar-disorder.core.v1 if MDQ ≥ 7 or manic features emerge on SSRI (APA 2024; STEP-BD Sachs 2007)
- Discharge from perinatal-specific care at 12 months postpartum if euthymic + supports in place; transition to general psychiatry or PCP for ongoing MDD maintenance if applicable (APA 2010 PPD)

Escalation triggers (move to higher acuity):
- Active SI with plan / intent / means OR recent attempt OR thoughts of harming infant → IMMEDIATE ED evaluation; routes to psych.suicidality.ed.core.v1 (Trost MMWR 2022 PMID 35587456; APA 2010 PPD)
- Emerging psychotic features (hallucinations / delusions / disorganised thought-behaviour) → re-evaluate for postpartum psychosis; route to psych.postpartum-psychosis.v1 (ACOG 757 2018/2024)
- Manic / hypomanic features on SSRI initiation → DISCONTINUE SSRI + perinatal psych same-day + route to psych.bipolar-disorder.core.v1 (STEP-BD Sachs NEJM 2007 PMID 17392295; APA 2024)
- EPDS ≥ 20 + functional impact + adequate SSRI trial failed at 4–6 wk → consider brexanolone IV OR zuranolone PO OR psychiatric admission (Meltzer-Brody 2018; Deligiannidis 2023; APA 2010 PPD)
- Severe functional collapse — unable to care for self or infant → ED / admit consideration; perinatal social work + family supports activated (APA 2010 PPD)
- Infant attachment disturbance + maternal disengagement → mother-infant dyadic therapy + perinatal social work (PSI 2024; Murray 1996)
- Substance-use relapse with concurrent rising SI / functional decline → SUD + perinatal psych integrated visit; ED if SI plan/intent (SAMHSA TIP 51 2018)

Patient Action Plan

**Postpartum depression self + family management plan + warning signs (ACOG 757 2018/2024; USPSTF 2019; APA 2010 PPD; NICE NG192 2024; PSI 2024)**
Personalised values: current_ssri_and_dose, current_psychotherapy_arrangement, breastfeeding_status, support_people_names_numbers, infant_caretaker_arrangement, lethal_means_restriction_plan, perinatal_psychiatrist_contact, OB_contact, pediatrician_contact, sleep_target, partner_ppd_status, crisis_lines.

**Doing well — mood stabilising, EPDS / PHQ-9 trending down, bonding with infant, sleeping when opportunity (APA 2010 PPD; PSI 2024)** (green):
Triggers:
- Mood improving + functional capacity restored (APA 2010 PPD)
- EPDS or PHQ-9 trending down on serial screening (Cox 1987; Kroenke 2001)
- Bonding + engaging with infant (PSI 2024)
- Taking SSRI as prescribed (APA 2010 PPD)
- Attending psychotherapy sessions if referred (USPSTF 2019; APA 2010 PPD)
- No suicidal thoughts on serial C-SSRS (Posner 2011)
- Family supports engaged (PSI 2024)
- Lethal-means restriction in place (VA/DoD 2019)
Actions:
- Take SSRI every day at same time — do NOT stop without provider (APA 2010 PPD)
- Continue psychotherapy as scheduled (USPSTF 2019)
- Attend perinatal psychiatry + OB + pediatric appointments (APA 2010 PPD; ACOG 757 2018/2024; PSI 2024)
- Prioritise sleep opportunities — partner / family help with overnight infant care (APA 2010 PPD)
- Avoid alcohol + recreational drugs + new prescription stimulants without provider (SAMHSA TIP 51 2018)
- Confirm lethal-means restriction stays in place (VA/DoD 2019)
- Keep crisis lines accessible — 988 + 1-800-944-4773 (PSI) (SAMHSA TIP 50 2015; PSI 2024)
- Engage partner / family in mother-infant bonding (PSI 2024)
- Maintain mother-baby support group attendance (PSI 2024)

**Warning — early signs of relapse or new symptoms (worsening mood, sleep < 4 h × 2 d, increasing anxiety, intrusive thoughts about infant) (APA 2010 PPD; NICE NG192 2024; PSI 2024)** (yellow):
Triggers:
- Worsening mood / increased crying / hopelessness (APA 2010 PPD)
- Sleeping < 4 h/night × ≥ 2 d (Bergink 2012; APA 2010 PPD)
- Increasing irritability or anxiety (APA 2010 PPD)
- Intrusive thoughts about the infant (even without intent to act) — distinguishing PPD obsessions from psychotic command hallucinations (PSI 2024; Brockington 2004)
- Missed medication doses (APA 2010 PPD)
- Difficulty bonding with infant (PSI 2024)
- Withdrawal from family or social supports (APA 2010 PPD)
- Increased alcohol or substance use (SAMHSA TIP 51 2018)
Actions:
- Use your personal early-warning-sign list + crisis plan IMMEDIATELY (NICE NG192 2024; PSI 2024)
- Tell partner / trusted family AND your perinatal psychiatrist within 24 h (PSI 2024)
- Prioritise sleep — partner to take infant overnight if needed (APA 2010 PPD)
- Check medication adherence — resume immediately if missed; do NOT double dose (APA 2010 PPD)
- Avoid major decisions, new commitments until reviewed (APA 2010 PPD)
- Confirm someone safe is with you AND with infant (PSI 2024)
- Reach out to mother-baby support group or PSI HelpLine 1-800-944-4773 (PSI 2024)
Contact provider when:
- Sleep < 4 h × 2 consecutive nights (APA 2010 PPD)
- Warning signs persist > 24–48 h despite self-management (NICE NG192 2024)
- Return of any suicidal thoughts (Posner 2011; APA 2010 PPD)
- Missed > 2 doses of medication (APA 2010 PPD)
- Inability to sleep, eat, or care for self / infant (APA 2010 PPD; PSI 2024)
- Partner / paternal PPD warning signs (Paulson 2010)

**Medical alert — active suicidal thoughts with plan or intent, thoughts of harming infant, emerging psychotic features, manic features on SSRI, severe functional collapse (ACOG 757 2018/2024; Trost MMWR 2022; APA 2010 PPD; STEP-BD Sachs 2007)** (red):
Triggers:
- Thoughts or urges to harm yourself OR your baby (Trost MMWR 2022 PMID 35587456; ACOG 757 2018/2024)
- Suicide plan or intent or means (Posner 2011; Trost MMWR 2022)
- Hearing voices, paranoia, grandiose beliefs not reality-based — possible postpartum psychosis (ACOG 757 2018/2024; DSM-5-TR)
- Manic features on SSRI — decreased need for sleep + pressured speech + racing thoughts + grandiosity + risk-taking — STOP SSRI + call perinatal psych (STEP-BD Sachs 2007; APA 2024)
- Severe functional collapse — unable to care for self or infant (APA 2010 PPD)
- New severe insomnia + confusion + fluctuating cognition (NICE NG192 2024)
Actions:
- Call 988 (US) / local crisis line / 911 NOW (SAMHSA TIP 50 2015)
- Postpartum Support International HelpLine 1-800-944-4773 (text / call) (PSI 2024)
- Go to nearest emergency department immediately; do NOT drive yourself if confused (APA 2010 PPD)
- Make sure baby is with another safe caretaker BEFORE you go OR call 911 to coordinate (PSI 2024)
- Hand any firearms, excess medications, car keys to a trusted person (VA/DoD 2019; APA 2010 PPD)
- Activate your safety plan; bring medication list (Stanley-Brown 2012 PMID 22642958)
- STOP your SSRI ONLY if you are having manic features AND call provider — do not stop SSRI for any other reason without provider (STEP-BD Sachs 2007)
Contact provider when:
- Any red zone trigger — emergency department immediately (ACOG 757 2018/2024; Trost MMWR 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Active suicidal ideation with plan / intent / means OR recent suicide attempt OR thoughts of harming infant in postpartum patient with depressive symptoms — life-threatening; suicide is a leading cause of maternal mortality through 1 year postpartum (Trost MMWR 2022 PMID 35587456; Posner 2011 PMID 22193671; ACOG 757 2018/2024)
- [LIFE_THREATENING] Hallucinations, delusions, or grossly disorganised thought / behaviour emerging in a postpartum patient with depressive symptoms — re-evaluate for postpartum psychosis; routes to psych.postpartum-psychosis.v1 (ACOG 757 2018/2024; APA 2010 PPD)
- [SEVERE] EPDS ≥ 20 + functional impact + (adequate SSRI trial failed at 4–6 wk OR rapid relief needed OR severe presentation) — eligible for brexanolone IV 60-h infusion at REMS-accredited site OR zuranolone 50 mg PO daily × 14 days outpatient (Meltzer-Brody Lancet 2018 PMID 30253856; Deligiannidis AJP 2023 PMID 37467049; APA 2010 PPD)

Citations

- ACOG Committee Opinion 757 (2018, reaffirmed 2024) — Screening for Perinatal Depression + USPSTF 2019 (Curry JAMA PMID 30747971) — Interventions to Prevent Perinatal Depression + NICE NG192 (2014, last updated 2024) Antenatal and Postnatal Mental Health + APA Practice Guideline on Postpartum Depression (2010) + Postpartum Support International (PSI) Perinatal Mental Health Certification 2024 [PMID:30253856](https://pubmed.ncbi.nlm.nih.gov/30253856/)
- Cited evidence (PMID 37467049) [PMID:37467049](https://pubmed.ncbi.nlm.nih.gov/37467049/)
- Cited evidence (PMID 3651732) [PMID:3651732](https://pubmed.ncbi.nlm.nih.gov/3651732/)
- Cited evidence (PMID 33208495) [PMID:33208495](https://pubmed.ncbi.nlm.nih.gov/33208495/)
- Cited evidence (PMID 11556941) [PMID:11556941](https://pubmed.ncbi.nlm.nih.gov/11556941/)

Last reconciled with current guidelines: 2026-05-15.
References
  • ACOG Committee Opinion 757 (2018, reaffirmed 2024) — Screening for Perinatal Depression + USPSTF 2019 (Curry JAMA PMID 30747971) — Interventions to Prevent Perinatal Depression + NICE NG192 (2014, last updated 2024) Antenatal and Postnatal Mental Health + APA Practice Guideline on Postpartum Depression (2010) + Postpartum Support International (PSI) Perinatal Mental Health Certification 2024 — PMID:30253856
  • Cited evidence (PMID 37467049) — PMID:37467049
  • Cited evidence (PMID 3651732) — PMID:3651732
  • Cited evidence (PMID 33208495) — PMID:33208495
  • Cited evidence (PMID 11556941) — PMID:11556941