154 The many antidepressants available are clearly effective for depression but are generally unstudied for PPD. Other considerations

in the selection of an antidepressant are the patient’s tolerability of side effects and the response to a previously prescribed antidepressant. For women with previous episodes of depression, the general guideline is to prescribe the antidepressant used in the previous episode if the patient had a satisfactory response. A major concern about drug therapy for breast-feeding mothers is the effect of medication on the Inhibitors,research,lifescience,medical infant.155 In small studies, amitriptyline, nortriptyline, desipramine, clomipramine, imipramine, sertraline, fluvoxamine, and paroxetine were not detected in quantifiable amounts in infant, plasma and all infants were thriving.156-161 The results are encouraging, but cannot be generalized to all infants exposed Inhibitors,research,lifescience,medical to these medications. Because of the high risk of repeated PPD, the question of prophylactic treatment is important but unanswered. In the only controlled study of an antidepressant administered

as a prophylactic, the Inhibitors,research,lifescience,medical tricyclic antidepressant, nortriptyline, initiated immediately postpartum in nondepressed women at risk of a subsequent PPD, was not better than placebo; 25% of the women in each group had a recurrence of PPD.162 Hormone treatments Sublingual 17β-estradiol (1 mg, 3 to 8 times/day to achieve a serum Integrase inhibitor review concentration of 400 pmol/L) in open treatment for 8 weeks resulted in rapid and Inhibitors,research,lifescience,medical significant improvement for women with severe PPD.163 The women had very low serum estradiol concentrations at the pretreatment baseline (mean = 21.7 pg/mL), but whether the low estradiol levels differed from those of asymptomatic postpartum women could not be determined in the absence of a control group. Women with postpartum psychosis also responded to 17β-estradiol treatment in a similar study conducted by the same researchers.164 Transdermal 17β-estradiol (delivery of 200 μg/day for 6 months) was significantly better than placebo for PPD, meeting criteria for Inhibitors,research,lifescience,medical major depressive

disorder.165 The response occurred in the first month of treatment and was sustained for the 6 months of the randomized, double-blind ADAMTS5 study. The effect on symptoms of a progestin added after 3 months was not reported; endometrial curettage at the end of treatment showed endometrial changes (sic) in three women, which resolved on follow-up. A very small open pilot study administered estrogen immediately after delivery to prevent recurrent PPD.166 A much lower relapse rate than expected in the ensuing year (9% versus an expected 35% to 60% without prophylaxis) suggested the utility of estrogen for high-risk women and supported the hypothesis that PPD may be triggered by rapid changes in the levels of estradiol in vulnerable women.