Postnatal Depression — MRCPsych Paper B MCQ

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ModeratePerinatal PsychiatryPostnatal DepressionMRCPsych Paper B

A 28-year-old woman develops severe depression 8 weeks after an uncomplicated term delivery. She is breastfeeding a healthy infant and has not previously received antidepressant treatment. Following an individualised discussion of the benefits and risks, an antidepressant is to be initiated alongside appropriate psychological and perinatal mental health care. Which antidepressant is preferred from the following options because infant exposure through breast milk is generally low?

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Correct answer: A — Sertraline

Sertraline is the preferred answer. It is an SSRI with low transfer into breast milk, and infant serum concentrations are usually negligible or undetectable. NICE permits antidepressant medication for severe postnatal depression after an individualised discussion and stresses that previous response and the risks of switching must be considered. The stem therefore specifies that treatment is being initiated rather than replacing an effective drug. Fluoxetine has a long half-life and greater potential for accumulation in the infant. Venlafaxine and its active metabolite enter breast milk to a greater extent. Mirtazapine has less extensive lactation evidence, while clomipramine is not normally preferred when initiating treatment because of its less favourable adverse-effect and toxicity profile. The breastfed infant should still be monitored for adverse effects, feeding and weight gain.

Reference: Den Besten-Bertholee D, et al. Sertraline, citalopram and paroxetine in lactation: passage into breastmilk and infant exposure. Frontiers in Pharmacology. 2024. https://www.nice.org.uk/guidance/cg192/chapter/Recommendations