Atricyclic antidepressant and a selective serotonin reuptake inhibitor
(SSRI) provided comparable symptom reduction among women with postpartum major
depression, according to a randomized comparative study.
The eight-week, double-blind trial of the tricyclic nortriptyline and the
SSRI sertraline included a 16-week continuation phase. Published in the August
Journal of Clinical Pharmacology, the study found that groups of
participants divided between the two drugs had the same response rates at
four, eight, and 24 weeks.
Findings from the 109 patients enrolled in the study ran counter to the
expectations of the researchers, who anticipated that the SSRI would be more
effective, due to findings pointing to such a conclusion from previous pilot
"These two drugs from different antidepressant classes were equally
effective for response and remission for postpartum depression," said
Katherine Wisner, M.D, the study's lead author. "So it's reasonable to
use drugs from either of these two classes."
Wisner is a professor of psychiatry, obstetrics, and gynecology and
director of Women's Behavioral Healthcare, at Western Psychiatric Institute
and Clinic at the University of Pittsburgh.
The eligibility and outcomes were measured with a 17-item Hamilton Rating
Scale for Depression (Ham-D), and other measures looked for side effects.
At four weeks, 25 of the 55 women (46 percent) taking sertraline responded
to the medication—defined as a 50 percent reduction in their Ham-D
score—and 30 patients of 54 patients (56 percent) taking nortriptyline
An additional 15 patients (27 percent went into remission on
sertraline—defined as a Ham-D score of less than 7—while 16 women
(30 percent) did so on nortriptyline.
By the eighth week, 94 percent of study participants had Clinical Global
Improvement scores that indicated significant improvement, and there were no
significant differences between patients on the two groups of drugs.
The study authors observed no adverse effects in babies of breastfeeding
mothers, and tests showed that serum levels in those infants were near or
below the "level of quantifiability" for both drugs.
The findings could have a broad impact because previous research has
identified depression in nearly 15 percent of women within the first three
months after giving birth.
Ruta Nonacs, M.D., Ph.D., who provides extensive postpartum depression
care, said the findings fill a void in research on the efficacy of tricyclic
antidepressants in postpartum patients and make her more inclined to prescribe
"This makes me more comfortable with using tricyclics, which do look
like they work quite well," Nonacs said.
A more subtle finding that surprised Nonacs, associate director of the
Center for Women's Health at Massachusetts General Hospital and an instructor
in psychiatry at Harvard Medical School, is that the study seemed to refute
the general belief among psychiatrists and other physicians that SSRIs are
better at treating intrusive obsessive symptoms in women.
"But both antidepressants worked equally well in taking care of those
obsessive symptoms," Nonacs said. "So it seems like it's not
necessarily an OCD symptom that you are treating but the overall level of
anxiety, and those OCD-type symptoms resolved."
Nonacs, who said that half of her patients are being treated for postpartum
depression, noted that another important finding of the study is that many
women, regardless of which drug they were taking, began responding by two
weeks into the trial.
Little was previously known about the treatment response rates for
medication among women with postpartum depression, so the researchers
hypothesized that they would be similar to the drugs' efficacy in treating
major depression. The findings support that assumption.
APA Vice President Nada Stotland, M.D., M.P.H., agreed that the findings
appeared to expand the medical options of physicians treating depression,
especially for those concerned that nursing mothers' exposure to SSRIs may be
associated with impaired neurocognitive development in their children.
The study's finding are unique in many areas because it is still rare for
researchers to conduct work with pregnant and breastfeeding women because of
concerns for the health of the child, said Stotland, an expert on women's
mental health and a professor of psychiatry and obstetrics/gynecology at Rush
Medical College in Chicago. The safety and efficacy findings are important in
this class of patients because they may encourage women to continue their drug
therapy and avoid the high depression relapse rates previous research has
identified among women who discontinue treatment while breastfeeding. Other
research has found that delaying treatment is the most significant factor in
the duration of depression.
"Ultimately, what is good for mommy is good for baby," Stotland
said. "A depressed mother doesn't eat well, doesn't sleep well, and
isn't going to be able to take good care of the baby."
The study's safety findings, Stotland said, also support the understanding
that psychiatrists should continue medical therapy in the postpartum period
for women already on antidepressants. However, women who are newly diagnosed
with postpartum depression should always begin treatment with psychotherapy,
except in cases of severe depression.
The study was funded by NIMH. Pfizer provided the sertraline.
"Postpartum Depression: A Randomized Trial of Sertraline
Versus Nortriptyline" is posted at<www.psychopharmacology.com.
Click on the "Search" tab, then enter "Wisner" as
author, and "sertraline" in the Title field. >.▪