Perinatal Antidepressant Decision Support

Perinatal Antidepressant Decision Support

Personalized guidance for choosing antidepressants before, during, and after pregnancy

Inspired by the PETRUSHKA approach: The PETRUSHKA trial (JAMA 2026, N=520) showed that combining clinical predictors with patient side-effect preferences reduced antidepressant discontinuation by 38% (aRR 0.62, 95% CI 0.44-0.88) and improved depression scores at 24 weeks (PHQ-9 difference: -1.92, P<.001). This tool applies a similar preference-based framework to the perinatal period.

Select the Clinical Phase

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Preconception
Planning pregnancy while on or considering antidepressants
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During Pregnancy
New or ongoing antidepressant use during gestation
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Postpartum
Depression after delivery, including breastfeeding considerations
PUBLICATIONS USED IN THIS TOOL
1Cipriani A, Fernandes KBP, Mulsant BH, et al. A decision-support system to personalize antidepressant treatment in major depressive disorder: a randomized clinical trial. JAMA. Published online March 4, 2026. doi:10.1001/jama.2026.1327 RCTFramework: patient preferences + clinical predictors for personalized antidepressant selection (N=520, 47 sites, 3 countries)
2ACOG. Treatment and management of mental health conditions during pregnancy and postpartum: Clinical Practice Guideline No. 5. Obstet Gynecol. 2023;141(6):1262-1288. GuidelineSSRIs first-line for perinatal depression; 68% relapse upon discontinuation in pregnancy
3Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet. 2018;391(10128):1357-1366. Network Meta-AnalysisEfficacy and tolerability ranking of 21 antidepressants (N=116,477); side-effect profiles used for preference matching
4LactMed (Drugs and Lactation Database). National Library of Medicine. Bethesda, MD. Updated 2025. Lactation DataBreastfeeding safety: sertraline and paroxetine preferred SSRIs (sertraline RID ~0.5%, usually undetectable in infant serum)
5Deligiannidis KM, Meltzer-Brody S, Maximos B, et al. Zuranolone for the treatment of postpartum depression. Am J Psychiatry. 2023;180(9):668-675. RCTFirst oral FDA-approved postpartum depression treatment (Aug 2023); 14-day course, symptom improvement by day 3
6Simon GE. Picking antidepressants -- patient preferences beat biomarkers. JAMA. Published online March 4, 2026. doi:10.1001/jama.2026.0816 EditorialPatient preference offers clinical benefit with little risk, cost, or treatment delay
7Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):1284-1292. ValidationPHQ-2 screener used when formal PHQ-9 score unavailable; sensitivity 83%, specificity 92% for major depression

Assessment

Clinical History

Quick PHQ-2 Screener (Ref 7: Kroenke et al. Med Care 2003)
Over the last 2 weeks, how often has the patient been bothered by:
1. Little interest or pleasure in doing things?
2. Feeling down, depressed, or hopeless?
Or answer both questions above for an estimate

Phase-Specific Considerations

Side Effects to Avoid (Select Up to 5)

Which side effects matter most to your patient? This personalizes the recommendation following the PETRUSHKA approach (Ref 1).
0 of 5 selected

Personalized Recommendations

Clinical Decision Support Tool -- Does not replace clinical judgment. All recommendations must be individualized. Risk of untreated maternal depression (68% relapse upon antidepressant discontinuation; ACOG CPG No. 5) must be weighed against medication risks. Only 20-25% reach remission with the first antidepressant (STAR*D; Rush et al. Am J Psychiatry 2006;163:1905). Discuss risks and benefits with the patient as part of shared decision-making.

Sources: Cipriani et al. JAMA 2026 | ACOG CPG No. 5, Obstet Gynecol 2023;141:1262 | Cipriani et al. Lancet 2018;391:1357 | LactMed 2025 | Deligiannidis et al. Am J Psychiatry 2023;180:668