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Frequently Asked Questions

What are the recommendations for the management of depression during pregnancy?

Introduction
Depression affects approximately 14% to 23% of pregnant women.1,2 Studies have shown that only about 18% of women seek treatment during pregnancy or the postpartum period.3 Depression in pregnant women often goes unrecognized and untreated. The clinical features of depression, such as insomnia, change in appetite, and lack of energy may be misinterpreted and attributed to normal symptoms of pregnancy. Symptoms of depression and the use of antidepressant medications during pregnancy have been associated with negative adverse outcomes in the mother and newborn.1-4 In the mother, untreated depression can result in bleeding, cesarean section, noncompliance with prenatal care, preeclampsia, postpartum depression, use of illicit drugs and alcohol, spontaneous abortion, or suicide.4 Infants born to women with depression are at risk for preterm birth and admission to the neonatal intensive care unit, low birth weight (<2500 grams) or small for gestational age (birth weight <10% of age-adjusted weight infants), and lower Apgar scores.1-3 Maternal depression has not been linked to congenital defects; however, infants born to women with depression are at increased risk for irritability, less activity and attentiveness, and fewer facial expressions.1,2

Selective serotonin reuptake inhibitors (SSRIs) are the most frequently prescribed medications for the treatment of depression during pregnancy, and their use is on the rise.1,2,4,5 Compared with tricyclic antidepressants, SSRIs are better tolerated and more effective. Since other agents are not routinely used in clinical practice, only the safety of SSRIs in pregnancy will be reviewed here.

Similar to patients with untreated depression, infants born to women taking an SSRI are at risk for spontaneous abortion, preterm birth, low birth weight, and small for gestational age.1,2 However, studies have shown additional risks to the fetus in women taking an SSRI. Studies of infants with major birth defects found a slightly increased incidence of anencephaly, craniosynostosis, omphalocele, and ventricular outflow effects in infants exposed to SSRIs during the first trimester. Other studies found an increased risk of cardiac defects associated with first trimester exposure to paroxetine.1,2,4,5 Paroxetine increased the risk of atrial and ventricular septal defections, and as a result the Food and Drug Administration (FDA) changed the pregnancy category from C to D.4,6 All other SSRIs remain category C.

Negative effects and other perinatal complications have been reported in infants exposed to SSRIs during the third trimester.1,2,4,5 “Poor neonatal adaptation” has been linked to SSRI exposure near term; symptoms include tachypnea, hypoglycemia, temperature changes, irritability, a weak or absent cry, and seizures.1,2 Additional adverse outcomes that have been reported are cardiac dysrhythmias, respiratory abnormalities, and persistent pulmonary hypertension, a condition which can have serious consequences including neurodevelopmental abnormalities and death. 1,2,4,5 The most serious potential complication of near term exposure to SSRIs is QT prolongation which is a marker for sudden cardiac death.4

Recommendations
Recently the American Psychiatric Association (APA) in collaboration with the American College of Obstetricians and Gynecologists (ACOG) published a report for the management of depression during pregnancy.1,2 The joint report is the result of an extensive review and critical evaluation of the literature surrounding the risks associated with depression and antidepressant treatment during pregnancy. The goal of these recommendations is to assist physicians and patients when considering the risks and benefits of various treatment options. Strategies for the management of women with depression who are pregnant or planning to become pregnant are also provided.

In this report, algorithms illustrate the treatment options for common scenarios of women presenting to their physician while pregnant or planning a pregnancy.1,2 The APA and ACOG stress the importance of collaboration between the patient, obstetrician, and psychiatrist at all stages of pregnancy. Below is a summary of the recommendations for the various scenarios:

Women planning a pregnancy

  • Patients with mild or no symptoms for ≥6 months may be candidates for medication taper and discontinuation. A slow taper (25% reduction in dose) every 1 to 2 weeks is preferred in addition to close monitoring for relapse and medication withdrawal.
  • Patients with a history of severe, recurrent depressive symptoms, psychosis, bipolar disorder, or a history of a suicide attempt are not candidates for medication discontinuation.

Pregnant women not currently taking medication for depression

  • Patients resistant to taking medications may benefit from psychotherapy alone.
  • A patient willing to consider pharmacotherapy should discuss the risks and benefits of treatment with her obstetrician and psychiatrist.
  • If the decision is made to initiate therapy, factors including stage of gestation, symptoms, history of depression and comorbid conditions such as bipolar or panic disorder, substance abuse, or eating disorder must be explored. If possible, treatment should be delayed until the second trimester and newer antidepressants should be reserved as second-line therapy due to a lack of safety information.

Pregnant women with current or recent diagnosis of depression taking antidepressants

  • Women who are psychologically stable with no symptoms may be candidates for medication taper and discontinuation. Psychotherapy may be beneficial as a replacement for pharmacotherapy.
  • Patients with a history of severe, recurrent depression, even if asymptomatic or minimally symptomatic, are at high risk of relapse if medication is discontinued.
  • Patients who have recurrent depression or are symptomatic despite treatment with antidepressants should consider psychotherapy to augment pharmacotherapy.
  • Medication must be continued during pregnancy in the following cases: history of severe depression, suicide attempts, or significant weight loss; prior relapse or failure to psychotherapy and pharmacologic treatment; patients with a concurrent psychiatric condition (i.e. bipolar disorder).

All pregnant women

  • If the patient is acutely suicidal or psychotic, she should be referred to a psychiatrist and aggressively treated with medication.

Conclusion

The recommendations set forth by the APA and ACOG should serve as a resource for clinicians caring for pregnant women. The document is an attempt to help physicians and patients weigh the risks and benefits of various treatments for depression in pregnant women. However, there are no firm recommendations regarding which SSRI is the drug of choice once the decision is made to treat the patient with pharmacotherapy. Due to risks of cardiac malformations, paroxetine should be avoided if possible. Physicians must be diligent when choosing to initiate, or continue, an SSRI in pregnant women.

References

  1. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009;114(3):703-713.
  2. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry. 2009;31(5):403-413.
  3. Marcus SM. Depression during pregnancy: rates, risks and consequences--Motherisk Update 2008. Can J Clin Pharmacol. 2009;16(1):e15-e22.
  4. Courtney K. Use of SSRIs in pregnancy: neonatal implications. Nurs Womens Health. 2009;13(3):234-238.
  5. Anon. Safety of SSRIs in pregnancy. Med Lett Drugs Ther. 2008;50(1299):89-91.
  6. Food and Drug Administration. MedWatch: the FDA safety information and adverse event reporting program 2005. http://www.fda.gov/Safety/MedWatch/SafetyInformation/
    SafetyAlertsforHumanMedicalProducts/ucm152062.htm    . Accessed September 30, 2009.