Understanding Depression During Pregnancy and Postpartum, Part 3:Treatment of Perinatal Depression
Although there is limited evidence from research studies to guide the treatment of women with depression during pregnancy or lactation, there are many available treatment options that can decrease suffering and improve quality of life. Research focused on women during pregnancy or postpartum poses substantial ethical and practical challenges for the investigator, thus compromising the rapid accumulation of reliable data (Yonkers, 2007). Because of the absence of a large evidence base, the clinician must rely on weighing the available treatment options with the woman suffering from depression during pregnancy so that an understanding of the risk/benefit ratio of treatment versus no treatment is achieved.
Two common treatments for depression include either talk therapy (psychotherapy) or medication (often an antidepressant medication). Interestingly, despite the lack of a large evidence base to guide clinical decision making, antidepressant use during pregnancy has seen steady increases in rates of use. Recent estimates of antidepressant use in pregnant women range from 8-11% (Andrade et al, 2008) and it is estimated that one third of all pregnant women are exposed to a psychotropic medication at some point during pregnancy (Doering et al, 1978). This finding highlights the importance of understanding the effects of these medications on the developing fetus and on the pregnant woman.
However, the risks of medication exposure must be weighed against the risks associated with untreated depression during pregnancy. Pregnancy does not protect against the occurrence of depression, and the likelihood of relapse is very high in untreated women with recurrent illness (Rubinow et al, 2006). The risks of untreated depression during pregnancy include the risk of ongoing depressive illness in the mother into the postpartum period, which may impair bonding between the mother and child, as well as the potential risk of impaired cognitive, emotional and social development in the child (Murray et al, 1999). Research suggests that women who stop or decrease the dose of their antidepressant therapy during pregnancy are at a significantly higher risk of relapse of major depression. (Cohen et al, 2006; Cohen et al 2004).
The American College of Obstetrics and Gynecology (ACOG) published a practice bulletin in April 2008 describing clinical management guidelines for the use of psychiatric medications during pregnancy and lactation (ACOG Committee on Practice Bulletins, Obstetrics and Gynecology, 2008). In this practice bulletin, ACOG recognized that the most commonly prescribed class of antidepressant medications are the selective serotonin reuptake inhibitors (SSRIs), and most of the data related to antidepressant use in pregnancy is focused on this class of antidepressants (fluoxetine, sertraline, citalopram and paroxetine) ( ACOG Practice Bulletin, 2008). Furthermore, a review of the current literature on SSRIs in pregnancy demonstrates that there is limited evidence that SSRI’s cause birth defects in early pregnancy; a notable exception being the small increased risk of cardiac defects associated with first trimester paroxetine exposure (Wen et al, 2006; Malm et al 2005; Einarson et al, 2005; Louik et al, 2007; and Alwan et al, 2007).
Later pregnancy exposure (third trimester) to SSRIs remains an ongoing source of controversy. There have been reports of very short-term neonatal complications, attributed to either SSRI toxicity versus withdrawal. This can include jitteriness, mild respiratory distress, weak cry, poor tone and increased rates of neonatal intensive care unit admission, and very rarely newborn persistent pulmonary hypertension (Moses-Kolko et al, 2005; Chambers et al, 1996; Costei et al, 2002; Kallen et al, 2004; Zeskind et al, 2004,Chambers et al, 2006).
The risks of taking medicine to treat depression have to be weighed against the risks of untreated depression. Women who are pregnant or breastfeeding should always talk with their doctors about the advantages and risks of taking antidepressant medicines. It is a decision that women need to discuss carefully with their doctors (including obstetrical care and mental health providers), and an individual plan must be developed for each person. Women who decide to take antidepressant medicines should discuss with their doctors which antidepressant medicines are safer to take while pregnant or breastfeeding.