Publication:

Treatment-resistant depression management in postpartum depression – a case report and literature review

Postpartum depression (PPD) affects approximately 10-15% of women and can cause significant morbidity for mothers, infants, and families. When postpartum depression fails to respond to two adequate trials, it is called as treatment resistant postpartum depression (TRPPD). Treatment of TRPPD is challenging because of breastfeeding, limitation of medication and competing childcare responsibilities. We report the case of a 26-year-old female with a history of anxiety, ADHD, and depressive disorders who developed severe postpartum depression following her two pregnancies. Following her second delivery, she developed severe depressive symptoms within three weeks postpartum, with a PHQ-9 score of 28. Despite multiple sequential pharmacological regimens including desvenlafaxine with bupropion and subsequent dose adjustments, the patient showed only partial and transient improvement. Significant clinical response was achieved after addition of cariprazine along with intensive psychotherapy and structured psychosocial support, including enhanced caregiving assistance. Her PHQ-9 decreased to 5 three weeks after initiation of this regimen. Sustained remission was observed over long-term follow-up continuing to this day. This case demonstrates the complexity of TRPPD and the limitations of monotherapy. Early detection of treatment resistance is crucial in avoiding impaired infant bonding and long-term maternal dysfunction. A multimodal approach comprising psychotherapy, augmentation techniques, antidepressant optimization, and psychosocial support is needed for effective management and long-term remission. TRPPD is a difficult and underdiagnosed disorder that requires individualized, multidisciplinary care. In refractory circumstances, combination medication and targeted psychological therapies may improve effectiveness. More research is required to develop evidence-based treatment approaches and uniform diagnostic standards for TRPPD.