Previous changes

April 2025 — minor update. QOF indicators removed in line with NHS England's 2025 Quality and Outcomes Framework.

November 2023 — reviewed. A literature search was conducted in October 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to recommendations have been made.

April 2022 — minor update. Telephone number for UKTIS has been updated.

August 2020 — minor update. Broken URL link updated.

July 2020 — minor update. A typographical error has been corrected.

September to November 2018 — reviewed. A literature search was conducted in September 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. A new section on prognosis has been added. There have been no major changes to recommendations, however, assessment, diagnostic, and management recommendations have been updated in line with the NICE Antenatal and postnatal mental health: clinical management and service guidance. Detail on the risks of individual antidepressants in pregnancy and breastfeeding has been removed and links to specialist sources of information included. Prescribing information specifically relevant to antidepressants in the antenatal and postnatal period is now included in the management scenarios. General antidepressant prescribing information is available in the CKS topic on Depression.

September 2015 — minor update. Typographical error corrected.

July 2013 — minor update. Links to the DVLA website have been updated.

June 2013 — minor update. The 2013 QOF options for local implementation have been added to this topic.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

January 2013 — reviewed. A literature search was conducted in December 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. Due to conflicting data on the safety of antidepressants during pregnancy, CKS no longer make specific recommendations on antidepressant choices during pregnancy. CKS now recommends that specialist advice should be sought before starting antidepressant treatment in a woman with a new episode of antenatal depression, and before stopping or switching antidepressant in a woman who becomes pregnant whilst taking an antidepressant. No major changes have been made to the recommendations for managing breastfeeding women with postnatal depression; however, it is also recommended that the prescriber considers seeking specialist advice if considering antidepressant treatment for this group of women.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

March 2012 — minor update. The 2012/2013 QOF indicators have been added to this topic. Issued in April 2012.

June 2011 — minor update. The 2011/2012 QOF indicators have been added to this topic.

May 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.

March 2011 — minor update. The NICE quality standards for treating depression have been added.

March 2010 — minor update. Text added regarding the small increased risk of cardiovascular malformation associated with first trimester maternal exposure to fluoxetine.

June 2009 — minor update. Text added regarding the manufacturer's warning about the small increased risk of cardiovascular malformation associated with first trimester maternal exposure to paroxetine.

October 2008 — minor typographical correction.

October 2007 to March 2008 — developed as a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 November 2023.

HTAs (Health Technology Assessments)

No new HTAs since 1 November 2023.

Economic appraisals

No new economic appraisals relevant to England since 1 November 2023.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 November 2023.

Primary evidence

• Pillinger, T., Arumuham, A., McCutcheon, R.A., et al. (2025) The effects of antidepressants on cardiometabolic and other physiological parameters: a systematic review and network meta-analysis. The Lancet. https://www.thelancet.com [Free Full-text]

New policies

No new national policies or guidelines since 1 November 2023.

New safety alerts

No new safety alerts since 1 November 2023.

Changes in product availability

• New product, zurzuvae (zuranolone) hard capsules, is licensed for the treatment of moderate or severe postnatal depression in adults following childbirth. See more here. 

Basis for recommendation

The information on how to assess for perinatal depression is based on expert opinion in the National Institute of Health and Care Excellence guideline Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2020].

Depression identification questions

• NICE recommends asking two focused questions to initially identify perinatal depression. It is advised that they are asked at first contact with primary care, or during a woman's booking appointment, and during the early postnatal period, as part of a general discussion about the woman's mental health and wellbeing [NICE, 2020]:  
  • The questions relate to mood and interest and are practical for use in a primary care setting in pregnancy and the postnatal period. They  have been found in studies to have a sensitivity of 100% for ruling out depression during this time, although the questions had low specificity and a significant number of false positive results.
  • The advantages of these questions include their brevity and convenience, that they do not require additional resources, and that they can be used by healthcare professionals who are not specialists in mental health in pregnancy and the postnatal period. 
  • NICE recommends that if the answers to these questions suggest depression, more detailed assessment is indicated.

Basis for recommendation

The information on how to assess a woman with suspected antenatal or postnatal depression is largely based on expert opinion in the National Institute of Health and Care Excellence (NICE) guideline Antenatal and postnatal mental health: clinical management and service guidance  [NICE, 2020].

Assessment and diagnosis

• NICE recommends a two-step process to identify depression in the antenatal and postnatal period (two question screening questionnaire, followed by more in-depth assessment if either of the two questions elicit a 'yes' answer) [NICE, 2020].
• The recommendation to also undertake further assessment where the screening questions do not raise concern of depression, but the woman is considered to be at risk of a mental health problem, or if there is a cause for clinical concern, is based the opinion of the NICE guideline development group (GDG) .
  • It was highlighted that use of the two screening questions may still fail to identify depression for some women due to factors including unwillingness to disclose or discuss mental health problems because of fear that healthcare professionals might view them negatively in their role as a mother, or that their baby might be at risk of being taken into care, and also that avoidance may be associated with some anxiety disorders, as well as drug or alcohol dependence.
• The information on clinical features of mental health problems in pregnancy and the postnatal period is largely based on the NICE guideline Antenatal and postnatal mental health: clinical management and service guidance  [NICE, 2020]. In the absence of high-quality evidence, the GDG based some of these features on those detailed in other relevent NICE guidelines, as well as their own expert opinion, and that of other contributors to the guideline development process . CKS has also included information from an international position paper on perinatal mental health [Brockington, 2017] and expert opinion in a clinical practice article Postpartum depression [Stewart, 2016] and the BMJ Best Practice guideline Postnatal depression [BMJ Best Practice, 2022].

The Edinburgh Postnatal Depression Scale (EPDS) 

• The EPDS is less well-validated for screening for depression in pregnancy compared with during the postnatal period. However, the NICE GDG noted that the EPDS and Patient Health Questionnaire (PHQ-9) have good sensitivity and specificity overall and can therefore be used for assessing women with a positive response to the depression identification questions. While the GDG noted that one study had found that a higher EPDS cutoff score may be required for the accurate identification of depression in pregnancy vs. the postnatal period, other studies did not agree with this finding and NICE made no recommendations on a different cutoff  [NICE, 2020].

Assessment of severity 

• The recommendation to assess the severity of prenatal or postnatal depression is based on the fact that NICE bases its treatment recommendations on the severity of a woman's depression [NICE, 2020].

Investigations

• The advice to carry out investigations to rule out potential differential diagnoses is based on expert opinion in a clinical practice article on postpartum depression [Stewart, 2016] and the BMJ Best Practice guideline Postnatal depression [BMJ Best Practice, 2022]. 

Basis for recommendation

The recommendations on diagnosis of depression in pregnancy and the postnatal period are largely based on expert opinion in the National Institute for Health and Care Excellence (NICE) guideline Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2020], and the Canadian Best practice guidelines for mental health disorders in the perinatal period [BC Reproductive Mental Health Program, 2014].

Diagnostic criteria

• Standard diagnostic criteria are recommended based on a lack of evidence that there is a difference between the aetiology and course of depression at other times of life versus  antenatal or postnatal depression [NICE, 2020].
• Canadian and BMJ Best Practice guidelines suggest that the gold standard for diagnosis is confirmation with the DSM-5 criteria in conjunction with an assessment interview [BC Reproductive Mental Health Program, 2014; BMJ Best Practice, 2022]. 
• However, experts highlight that diagnosing depression in the perinatal period can be challenging due to the life changes occurring at this time. NICE highlights that some changes in mental state and functioning are normal at this time. A careful clinical assessment is needed to identify an underlying mental health problem when a woman is experiencing features such as sleep disturbance, tiredness, and anxious thoughts about the baby [NICE, 2020].
• The information on what to include in an assessment is based on expert opinion from NICE [NICE, 2020] and an international position paper on perinatal mental health [Brockington, 2017].

Basis for recommendation

The information on the potential differential diagnoses of depression in the pre- and postnatal periods is based on expert opinion in the National Institute of Health and Care Excellence (NICE) guideline Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2020], the BMJ Best Practice guideline Postnatal depression [BMJ Best Practice, 2022], a Canadian Best practice guidelines for mental health disorders in the perinatal period [BC Reproductive Mental Health Program, 2014], as well as a Cochrane systematic review [Molyneaux, 2014], and a number of further review articles [Jones, 2014; Langan and Goodbred, 2016; Stewart, 2016; Kendig et al, 2017].

How should I manage a woman on an antidepressants who is planning a pregnancy ?

Note: Consider referring women with a current or past severe mental health problem who are planning a pregnancy to a secondary mental health service (preferably a specialist perinatal mental health service) for preconception counselling. Patient-specific information and risk assessment are also available from the UK Teratology Information Service (UKTIS) via their telephone line (0344 892 0909).

For women on antidepressants who are planning a pregnancy:

• Carry out a review to determine the nature of the woman's depression, the severity of symptoms, the effectiveness of the current treatment, and any psychiatric and physical comorbidities to determine whether the antidepressant can be safely stopped or switched.
  • Antidepressants can be used while trying to conceive and at any stage of pregnancy if clinically indicated and should not be withheld on the basis of pregnancy/planning a pregnancy.
  • Shared-decision making and person-centred care are crucial. 
• Consider the risk of destablisation of the woman's condition if thinking of stopping, switching, or reducing the dose of an existing antidepressant.
  • For women who are stable on current treatment, it may be safer to maintain their therapy.
  • The lowest effective dose should be prescribed, but ensure that depression is adequately treated.
  • If considering switching medication, take into account previous history and response to treatment, as well as the woman's relationships with, and level of support from, family or carers and the needs of her family.
  • A single drug should be used, if possible, rather than two or more drugs. However, for women already stabilised on polytherapy, consider the risk of destablisation if treatment is altered. Specialist input is likely to be required for complex cases.
  • See the section on Managing a new episode in pregnancy for information on non-pharmacological treatments for depression if an alternative to antidepressant treatment is being considered.
    • An antidepressant should not be stopped abruptly. See the CKS topic on Depression for advice on tapering antidepressant treatment.
  • Seek advice from a secondary mental health service (preferably a specialist perinatal mental health service) and/or UKTIS if there is any uncertainty about the best course of action.
• Discuss with the woman (and her family where appropriate) the risks and benefits of antidepressant treatment:
  • The benefits of treatment to the woman, her unborn baby, and her wider family should be weighed against any possible adverse maternal and fetal effects; this risk-benefit ratio will be specific to each woman.
  • Be aware that pregnancy is a risk period for exacerbation of some mental health problems and that appropriate management of depression during pregnancy can reduce the risk of depression in the postnatal period.
  • Discuss with the woman the potential fetal risks of antidepressants, including that:
    • None are proven to cause birth defects, and although some have been associated with specific increased risks of adverse pregnancy outcomes, the absolute risk of fetal harm is low. 
    • There is more safety data for use in pregnancy of some antidepressants than others. SSRIs are considered to be the best studied.
    • See the section on Fetal effects of antidepressants for specific details of the risks of each antidepressant class.
  • Ask the woman about her plans regarding breastfeeding. Explain the risks associated with taking some psychotropic medications when breastfeeding. 
  • As no psychotropic medication has a UK marketing authorisation specifically for use in pregnancy or breastfeeding, informed consent should be obtained and documented if an antidepressant is prescribed for use in pregnancy.
• Offer the woman information and advice, including culturally relevant information on mental health problems in pregnancy and reassurance that mental health problems are not uncommon during this period and that treatment can alleviate symptoms.

How should I manage a woman on an antidepressant who becomes pregnant?

Note: Consider referring women with a current or past severe mental health problem who are planning a pregnancy to a secondary mental health service (preferably a specialist perinatal mental health service). Patient-specific information and risk assessment are also available from the UK Teratology Information Service (UKTIS) via their telephone line (0344 892 0909). 

For women on antidepressants who report an unplanned pregnancy:

• Carry out a review to determine the nature of the woman's depression, the severity of symptoms, the effectiveness of the current treatment, and any psychiatric and physical comorbidities, as well as the woman's treatment preferences, to determine whether the antidepressant can be stopped or switched.
  • Antidepressants can be used at any stage of pregnancy if clinically indicated, and should not be withheld on the basis of pregnancy.
  • Shared-decision making and person-centred care are crucial. 
• If continuation of antidepressant treatment is being considered, discuss with the woman (and her family where appropriate) the risks and benefits:
  
  • The benefits of treatment to the woman, her unborn baby, and her wider family should be weighed against any possible adverse maternal and fetal effects; this risk-benefit ratio will be specific to each woman.
  • Be aware that pregnancy is a risk period for exacerbation of some mental health problems and that appropriate management of depression during pregnancy is likely to reduce the risk of depression in the postnatal period.
  • Discuss with the woman the potential fetal risks of antidepressants, including that:
    • None are proven to cause birth defects, and although some have been associated with specific increased risks of adverse pregnancy outcomes, the absolute risk of fetal harm is low. 
    • There is more safety data for use in pregnancy of some antidepressants than others. SSRIs are the class with the most pregnancy safety data.
    • See the section on Fetal effects of antidepressants for specific risks of each antidepressant class.
  • Ask the woman about her plans regarding breastfeeding. Explain the possible risks associated with taking some psychotropic medications when breastfeeding. For further information, see the section on Management of depression in the postnatal period
• Consider the risk of destablisation of the maternal condition if thinking of stopping, switching, or reducing the dose of an existing antidepressant.
  • When assessing the possible risks of treatment alteration, take into account previous history and response to treatment, as well as the woman's relationships with, and level of support from, family or carers and the needs of her family (for example, the welfare of her baby and other children). 
  • For women who are stable on current treatment, it may be safer overall to maintain this.
  • The lowest effective dose should be prescribed, but ensure that depression is adequately treated.
  • A single drug should be used, if possible, rather than two or more drugs. However, for women already stabilised on polytherapy, consider the risk of destablisation if treatment is altered. Specialist input is likely to be required for complex cases.
  • As no psychotropic medication has a UK marketing authorisation specifically for use in pregnancy or breastfeeding, informed consent should be obtained and documented where use is to be continued in pregnancy.
  • Seek advice from a secondary mental health service (preferably a specialist perinatal mental health service) and/or UKTIS if there is any uncertainty about the best course of action.
• Where switching or cessation of treatment is being considered:
  • An antidepressant should not be stopped abruptly. See the CKS topic on Depression for advice on tapering antidepressant treatment.
    • Be aware that fetal development is complete by the end of week 11 of pregnancy. Depending on the current stage of pregnancy, gradual withdrawal may result in continued exposure to the drug throughout fetal organogenesis and, therefore, may offer little benefit in terms of attempting to mitigate any malformation risk.
  • Consider referral for facilitated self-help or a high-intensity psychological intervention (for example, CBT), depending on the severity of depression and the woman's wishes. 'Watchful waiting' may also be considered if clinically appropriate. For further information, see the CKS topic on Depression.
    • If the woman requires psychological treatment, ensure that she is assessed within 2 weeks of referral and is seen promptly for treatment (ideally, within 1 month of initial assessment). 
  • If a woman with depression decides to stop taking psychotropic medication during pregnancy, monitor her mental well-being because of the risk of relapse. Discuss with her:
    • Her reasons for stopping.
    • The possibility of other options: for example, having a psychological intervention, restarting medication if the depression is or has been severe and there has been a previous good response to treatment, or switching to other medication.
    • Increasing her monitoring and support while she is not taking any medication.
    • Any risks to herself, or the fetus or baby when stopping medication.
• Offer written information, for example, the Mind publication Understanding postnatal depression and perinatal mental health, available at www.mind.org.uk.
• Arrange appropriate follow up for a pregnant woman with depression:
  • Assess and agree on the level of contact and support needed. 
  • Regularly monitor symptoms.  At all contacts, consider asking the two depression identification questions as part of a general discussion about her mental health and well-being and using the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ-9) as part of monitoring.
  • Discuss how her symptoms will be monitored, for example, by using validated self-report questionnaires, such as the EPDS or PHQ-9. 
  • If a woman is on drug treatment, review frequently, with dose adjustment if necessary, particularly in later pregnancy. 

How should I manage a new episode of depression in a woman who is pregnant?

For women diagnosed with depression during pregnancy:

• Urgently refer to a secondary mental health team (ideally with a special interest in perinatal mental health) if a woman:
  • Is severely depressed and presents a considerable immediate risk of harm to herself or other people — admission may be required if clinically indicated.
  • Shows evidence of severe self-neglect or is unable to fulfil any caring duties. 
  • Has a possible diagnosis of bipolar disorder. For more information, see the CKS topic on Bipolar disorder. 
  • Has a history of severe mental illness, including postnatal depression, puerperal psychosis, or bipolar disorder (during pregnancy or the postnatal period or at any other time). 
• Refer to a specialist substance misuse service if, in addition to depression, the woman has harmful or dependent drug or alcohol misuse in pregnancy. 
• Specialist advice may be sought ideally from a specialist perinatal mental health team where available or a secondary mental health service or the UK Teratology Information Service (UKTIS) on 0344 892 0909.
• Other factors to be taken into account when deciding whether to refer include:
  • The woman's preference.
  • The woman's history and response to treatment.
  • The degree of functional impairment.
  • The presence of significant comorbidities or specific symptoms.

For women being managed in primary care:

• Consider the nature of the woman's depression, the severity of symptoms, the effectiveness of any previously-used treatment, and any psychiatric and physical comorbidities, as well as the woman's treatment preferences, to determine whether antidepressant treatment is appropriate.
  • Antidepressants can be used at any stage of pregnancy if clinically indicated, and should not be withheld on the basis of pregnancy.
  • Be aware that antidepressant use can be considered in women with currently mild symptoms but who have a history of severe depression.
  • Shared-decision making and person-centred care are crucial. 
• Where antidepressant treatment is being considered, discuss with the woman (and her family where appropriate) the risks and benefits:
  
  • The benefits of treatment to the woman, her unborn baby, and her wider family should be weighed against any possible adverse maternal and fetal effects; this risk-benefit ratio will be specific to each woman.
  • Be aware that pregnancy is a risk period for exacerbation of some mental health problems and that appropriate management of depression during pregnancy is likely to reduce the risk of depression in the postnatal period.
  • Discuss with the woman the potential fetal risks of antidepressants, including that:
    • None are proven to cause birth defects, and although some have been associated with specific increased risks of adverse pregnancy outcomes, the absolute risk of fetal harm is low. 
    • There is more safety data for use in pregnancy of some antidepressants than others. SSRIs are the class with the most pregnancy safety data.
    • See the section on Fetal effects of antidepressants for specific risks of each antidepressant class at different stages of pregnancy.
  • Ask the woman about her plans regarding breastfeeding. Explain the possible risks associated with taking some psychotropic medications when breastfeeding. For further information, see the section on Management of depression in the postnatal period
  • Base the choice of drug on the personalised risk: benefit analysis and the woman's preference:
    • The lowest effective dose should be prescribed, but ensure that depression is adequately treated.
    • A single drug should be used, if possible, rather than two or more drugs. Specialist input is likely to be required for complex cases.
    • As no psychotropic medication has a UK marketing authorisation specifically for use in pregnancy or breastfeeding, informed consent should be obtained and documented where use is to be continued in pregnancy.
  • Seek advice from a secondary mental health service (preferably a specialist perinatal mental health service) and/or from the UK Teratology Information Service (UKTIS) via their telephone line (0344 892 0909) if there is any uncertainty about the best course of action. Patient-specific risk assessment is also available from UKTIS.
• Where non-drug treatment is appropriate/preferred:
  
  • Consider referral for facilitated self-help or a high-intensity psychological intervention (for example, CBT), depending on the severity of depression and the woman's wishes. 'Watchful waiting' may also be an option if clinically appropriate. For further information, see the CKS topic on Depression.
    • If the woman requires psychological treatment, ensure that she is assessed within 2 weeks of referral and is seen promptly for treatment (ideally, within 1 month of initial assessment). 
• Offer written information, for example, the Mind publication Understanding postnatal depression and perinatal mental health, available at www.mind.org.uk.
• Arrange appropriate follow-up for a pregnant woman with depression:
  • Assess and agree on the level of contact and support needed. 
  • Regularly monitor symptoms.  At all contacts, consider asking the two depression identification questions as part of a general discussion about her mental health and well-being and using the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ-9) as part of monitoring.
  • Discuss how her symptoms will be monitored, for example, by using validated self-report questionnaires, such as the EPDS or PHQ-9. 
  • If a woman is on drug treatment, review frequently, with dose adjustment if necessary, particularly in later pregnancy. 
  • If the woman is experiencing ongoing symptoms despite medication alone, consider referral for a high-intensity psychological intervention in combination with medication.
  • Refer or seek specialist advice if the woman is not responding to treatment appropriate to the severity of her depression.
• If a woman with depression decides to stop taking psychotropic medication during pregnancy, monitor her mental status because of the risk of relapse. Discuss with her:
  • That an antidepressant should not be stopped abruptly. See the CKS topic on Depression for advice on tapering antidepressant treatment.
    • Be aware that fetal development is complete by the end of week 11 of pregnancy. Depending on the current stage of pregnancy, gradual withdrawal may result in continued exposure to the drug throughout fetal organogenesis and, therefore, may offer little benefit in terms of attempting to mitigate any malformation risk.
  • Her reasons for stopping.
  • The possibility of other options: for example, having a psychological intervention, restarting medication if the depression is or has been severe and there has been a previous good response to treatment, or switching to other medication.
  • Increasing her monitoring and support while she is not taking any medication.
  • Any risks to herself, or the fetus or baby when stopping medication.

How should I manage depression in the postnatal period?

Advice regarding the treatment of depression in a postnatal woman can be sought from a specialist perinatal mental health team, where available, or from secondary psychiatric care. Specialist advice regarding medication use in breastfeeding can be sought from the UK Drugs in Lactation Advisory Service (UKDILAS) on 0300 770 8564. Be aware that the postnatal period is a risk period for exacerbation of some mental health problems and that appropriate management is important to reduce this risk.

• Refer to a secondary mental health service, ideally a specialist perinatal mental health service, for immediate assessment (within 4 hours of referral) if a woman has a sudden onset of symptoms suggestive of postpartum psychosis. 
• Urgently refer to a secondary mental health team (ideally with a special interest in perinatal mental health) if a woman:
  • Is severely depressed and presents a considerable immediate risk of harm to herself or other people — admission may be required if clinically indicated.
  • Shows evidence of severe self-neglect or is unable to look after her baby. 
  • Has a possible diagnosis of bipolar disorder. For more information, see the CKS topic on Bipolar disorder. 
  • Has a history of severe mental illness, including postnatal depression, puerperal psychosis, or bipolar disorder (during pregnancy or the postnatal period or at any other time). 
    • Women who need inpatient care for a mental health problem within 12 months of childbirth should normally be admitted to a specialist mother and baby unit if locally available.
• Refer to a specialist substance misuse service if, in addition to depression, the woman has harmful or dependent drug or alcohol misuse. 
• Other factors to be taken into account when deciding whether to refer include:
  • The woman's preference.
  • The woman's history and response to treatment.
  • The degree of functional impairment.
  • The presence of significant comorbidities or specific symptoms.
• For women being managed in primary care:
  • Consider the nature of the woman's depression, the severity of symptoms, the effectiveness of any previously-used treatment, and any psychiatric and physical comorbidities, as well as the woman's treatment preferences, to determine whether antidepressant treatment is appropriate.
    • Antidepressants can be used during the postnatal period if clinically indicated.
    • Most antidepressants can be safely used during breastfeeding, although the baby should be monitored for adverse effects. Discuss with a paediatrician if the baby is premature or has health problems or liver or kidney impairment. 
    • Consider the risks of maternal destabilisation if thinking of stopping or switching an existing antidepressant. 
    • Shared-decision making and person-centred care are crucial. Where antidepressant treatment is being considered, discuss with the woman (and her family where appropriate) the risks and benefits.
    • Be aware that antidepressant use can be considered for women with currently mild symptoms but who have a history of severe depression.
  • A selective serotonin reuptake inhibitor (SSRI), tricyclic antidepressant (TCA), or (serotonin-) noradrenaline reuptake inhibitor [(S)NRI] can be used in the postnatal period: 
    
    • Note that no psychotropic medication has a UK marketing authorisation specifically for women who are breastfeeding, and informed consent should be obtained and documented.
    • The lowest effective dose should be prescribed, but ensure that depression is adequately treated. 
    • A single drug should be used, if possible, rather than two or more drugs.
  • When assessing the risks and benefits of TCAs, SSRIs, or (S)NRIs for a woman who is considering breastfeeding, the following should be taken into account: 
    • The benefits of breastfeeding for the woman and baby.
    • The limited data about the use of these drugs during breastfeeding.
    • The risks associated with switching or stopping a previously effective medication.
  • Paroxetine and sertraline are generally the SSRIs of choice for treatment initiated in breastfeeding women. Monitor infants for sedation, poor feeding and behavioural effects.
    • Other SSRIs and classes of antidepressants can be considered if the woman is already being successfully treated with one of these drugs. Seek specialist advice if unsure.
    • Tricyclic antidepressants (TCAs) are less commonly used than SSRIs for new episodes of postnatal depression because of concerns about maternal toxicity. If clinically appropriate, imipramine and nortriptyline are preferred. Doxepin should be avoided. Monitor infants for drowsiness, poor feeding, and behavioural changes if used during breastfeeding. 
  • For more information on antidepressants in breastfeeding, see the UK Drugs in Lactation Service (UKDILAS) website, and the Drugs and Lactation Database (LactMed).
• Where non-drug treatment is appropriate/preferred:
  
  • Consider referral for facilitated self-help or a high-intensity psychological intervention (for example, CBT), depending on the severity of depression and the woman's wishes. 'Watchful waiting' may also be an option if clinically appropriate. For further information, see the CKS topic on Depression.
  • If the woman requires psychological treatment, ensure that she is assessed within 2 weeks of referral and is seen promptly for treatment (ideally, within 1 month of initial assessment). 
• Offer written information, for example, the Mind publication Understanding postnatal depression and perinatal mental health, available at www.mind.org.uk.
• Encourage postnatal women to help look after their mental health, for example, by taking gentle exercise, resting, seeking help with caring for the baby, and talking to someone about how they are feeling. 
• Arrange appropriate follow up for a postnatal woman with depression:
  • Assess and agree on the level of contact and support needed. 
  • Regularly monitor symptoms.  At all contacts, consider asking the two depression identification questions as part of a general discussion about her mental health and well-being and using the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ-9) as part of monitoring.
    • At each postnatal contact, ask about the woman's emotional well-being, what family and social support they have and their usual coping strategies for dealing with day-to-day matters. Encourage women and their families/partners to tell their healthcare professional about any changes in mood, emotional state and behaviour that are outside of the woman's normal pattern. 
    • Consider assessing the mother-baby relationship at each postnatal contact, as this can be affected by maternal mental health problems. Assess verbal interaction, emotional sensitivity and physical care and, where appropriate, discuss any concerns the woman has about her relationship with her baby. Seek advice from a specialist perinatal mental health team
  • Discuss how her symptoms will be monitored, for example, by using validated self-report questionnaires, such as the EPDS or PHQ-9. 
  • If a woman is on drug treatment, review frequently, with dose adjustment if necessary. 
  • If the woman is experiencing ongoing symptoms despite medication alone, consider referral for a high-intensity psychological intervention in combination with medication.
  • Refer or seek specialist advice if the woman is not responding to treatment appropriate to the severity of her depression.
• If a woman with depression decides to stop taking psychotropic medication, monitor her mental status because of the risk of relapse. Discuss with her:
  • That an antidepressant should not be stopped abruptly. See the CKS topic on Depression for advice on tapering of antidepressant treatment.
  • Her reasons for stopping.
  • The possibility of other options: for example, having a psychological intervention, restarting medication if the depression is or has been severe and there has been a previous good response to treatment, or switching to other medication.
  • Increasing her monitoring and support while she is not taking any medication.
  • Any risks to herself or the baby when stopping medication.