Addressing the Treatment Challenges of Depression in Pregnancy

Approximately 13% of women suffer from depression during or after pregnancy.
Approximately 13% of women suffer from depression during or after pregnancy.

An estimated 13% of women suffer from depression during or after pregnancy, and treating the condition can be a challenge.1 Treatment decisions are getting even more complex since recent studies raised issues with the safety of selective serotonin reuptake inhibitors (SSRIs) during pregnancy. Sheila M. Marcus, MD, the co-director of the Women Mental Health and Infants Program at the University of Michigan in Ann Arbor, discusses how to evaluate risk and make prescribing decisions for expectant mothers.

RISKS OF ANTIDEPRESSANT THERAPY IN PREGNANCY

Recent studies have linked maternal use of SSRIs during pregnancy with reduced fetal head growth, preterm birth, and persistent pulmonary hypertension in newborns.2,3 How significant are these adverse outcomes versus the risks of untreated depression during pregnancy?

The use of SSRIs during pregnancy is associated with some risks, but overall problematic side effects of SSRI drugs to the fetus are quite rare. Most of the major studies that have looked at SSRIs and potential adverse outcomes have not adequately corrected for untreated maternal depression in pregnancy, which also presents potential risks to the developing fetus.

When a woman experiences a high degree of depression during pregnancy, her body goes into a chronic fight-or-flight mode. In this state, the body may funnel blood flow away from the fetus, slowing growth. In addition, some women don't eat properly when they are significantly depressed, preventing the fetus from getting proper nutrition. Women with depression are also less likely to regularly attend prenatal visits and may also suffer from inadequate or disrupted sleep, which further increases anxiety and depression. These factors can also impair fetal growth and raise the risk of preterm delivery. Practitioners must perform a balancing act when it comes to this issue, looking at the risks of SSRIs versus problems that may result from untreated depression.

Should these recent findings affect prescribing practices during pregnancy?

Practitioners should be aware of issues related to SSRI use during pregnancy and be certain to balance the risks and benefits when making prescribing decisions. I always recommend that women make the decision to use or not use SSRIs with their partner and physician.

ALTERNATIVE TREATMENTS

Are there any alternatives to SSRIs that are a viable option during pregnancy that should be explored?

We often recommend psychotherapy, such as interpersonal and cognitive behavioral therapy (CBT), instead of pharmacotherapy as a first-line treatment for pregnant women with mild to moderate depression. In addition to psychotherapy, other lifestyle interventions may also help reduce depressive symptoms, such as mild exercise, meditation or mindfulness-based cognitive therapy.

There are also other medications that can be explored, depending on the type and severity of symptoms. For women with bipolar spectrum disorders, mood stabilizers, such as lithium or lamotrigine, might be considered. During pregnancy, these represent a safer alternative to some of the anticonvulsants used for the same condition, which have higher base rates of anomalies. However, lithium may cause cardiovascular anomalies when prescribed in the first 12 weeks of pregnancy, and practitioners should monitor exposed fetuses with fetal surveys. A specialist or psychiatrist is generally the best person to make medication decisions for pregnant women with bipolar spectrum disorders.