Guidelines for the Management of Depression During Pregnancy

Abstract

Guidelines regarding the treatment of depression during pregnancy were recently published by the American Psychiatric Association and the American College of Obstetricians and Gynecologists. We provide a commentary on these guidelines.

Introduction

Recently, the American Psychiatric Association and the American College of Obstetricians and Gynecologists jointly published consensus guidelines regarding the management of depression during pregnancy [1]. The goal was to provide a comprehensive review of the literature and treatment recommendations by experts in the fields of perinatal psychiatry and obstetrics. This important publication is timely given the growing concerns about the use of antidepressants during pregnancy and the increasing and sometimes confusing body of literature that addresses this issue. The guidelines were published simultaneously in obstetric [1] and psychiatric [2] journals to increase the dissemination of this information to medical professionals. The resulting publication is essential reading, as it presents specific recommendations for a variety of clinical scenarios. However, like all guidelines, they cannot address every possibility and should not be used blindly in the absence of specific experience with this population or a full clinical examination of the individual patient. In addition, all guidelines suffer from the fact that the evidence base from which they are derived is constantly changing and can become outdated quickly. Therefore, clinicians must continue to monitor the literature, a complex and time-consuming endeavor. Professional, members-only websites such as http://www.reprotox.org can be an excellent source for clinicians, as information on specific medications is updated regularly. However, clinicians who have little experience in the treatment of pregnant women with psychiatric disorders may have difficulty interpreting the complexity of this literature. Finally, the medicolegal issues involved in treating this population also must be considered given the recent legal cases involving the use of paroxetine during pregnancy [3]. For these reasons, we recommend that the guidelines be used as an impetus to increase the recognition of depression during pregnancy, and when possible, referral to a psychiatrist should be considered.

Depression and Pregnancy

Depressive symptoms are prevalent during pregnancy. About 13% of pregnant women will experience a major depressive episode, which means that about half a million women in the United States will be affected each year [4]. The guidelines review the data regarding the following specific pregnancy-related events and depression: miscarriage, growth restriction, and preterm delivery. They conclude that the data do not conclusively support or refute a link between depression during pregnancy and these adverse outcomes. The same conclusion was reached regarding antenatal depression and adverse neonatal and childhood outcomes. Interestingly, little attention is given to the main adverse effect of depression during pregnancy, that of maternal suffering from the disease itself. It is generally accepted that depression in nonpregnant patients should be diagnosed as mild, moderate, or severe, and then specific treatment recommendations should be made based on this classification as well as comorbidity and prior treatment response. Depression is known to affect financial and relational stability as well as general health outcomes [5, 6]. The guidelines do note that substance abuse is more common in patients suffering from depression and can affect pregnancy outcomes. It is worth emphasizing here that depression is a disease with a known mortality rate of about 10% from suicidal behavior. Pregnant women should not be left untreated simply because they are pregnant and the fetal and neonatal effects of depression are not clearly determined at this time. This would be a misinterpretation of the data presented in and goals of the guidelines.

Treatment

Once depression is diagnosed in a pregnant woman, treatment should be prescribed. For mild to moderate depression, psychotherapy is recommended as a first-line treatment. Although there is a relative dearth of studies focusing on the efficacy of psychotherapy for depression during pregnancy, a great deal of data support its use in the nonpregnant population. Many forms of psychotherapy are available, and specific recommendations can be made based on the patient’s clinical presentation [7]. Considerations for recommending psychotherapy include the patient’s willingness, access to skilled practitioners, and financial accessibility. Pregnant patients are likely to prefer psychotherapy over medications [8], leaving the last two barriers to be overcome. However, not all patients—not even those with similar disease characteristics—will respond to a single prescribed treatment, including psychotherapy. Therefore, a patient who is referred for psychotherapy should continue to have her progress monitored so that alternatives can be prescribed if necessary.

Most of the American Psychiatric Association/American College of Obstetricians and Gynecologists guidelines focus on the use of antidepressants during pregnancy. The authors conclude that there are data supporting an association between selective serotonin reuptake inhibitor use and small for gestational age infants. Not enough data are available to conclude whether this is dependent on length of exposure, and the absolute difference in birth weight is small and of unclear clinical significance. Convincing data indicate that preterm delivery (defined as ≤37 weeks’ gestational age) is associated with antidepressant use during pregnancy, but again, the actual differences between exposed and unexposed groups are small. The guidelines report that antidepressants in aggregate are not associated with major congenital malformations, although paroxetine has been labeled by the US Food and Drug Administration as causative of septal heart defects in exposed infants. Poorer neonatal outcomes such as respiratory and feeding difficulties, jitteriness, and irritability are associated with third trimester use of antidepressants, although these symptoms tend to be transient. Two studies have linked selective serotonin reuptake inhibitor use to a less than 1% absolute risk of persistent pulmonary hypertension of the newborn, a potentially fatal functional abnormality.

The guidelines provide three flow charts for clinicians evaluating women with depression: 1) women who present for preconceptual counseling; 2) pregnant women with depression, not on antidepressants; and 3) pregnant women with depression on antidepressants. If a woman has a history of moderate to severe recurrent depression or is experiencing a moderate to severe depressive episode, the guidelines recommend initiation or continuation of an antidepressant. The guidelines only recommend discontinuing antidepressants in clinical scenarios in which women are minimally symptomatic for 6 months or longer and have no history of significant symptomatic relapse off medication. These treatment recommendations are based on the consensus of experts in the field due to a limited evidence base. However, they are exactly what we would recommend and therefore are likely to mirror the experience of many experts. The importance of these guidelines is that at no point is it suggested to counsel a woman to stop antidepressants without considering her psychiatric history and current symptoms. This is why we recommend that the clinician best suited to make these recommendations is a psychiatrist. In fact, we often recommend that as a practical exercise, the clinician should decide what recommendation he or she would make to the patient in the absence of a potential or current pregnancy [9]. This can clarify the clinician’s thinking about the patient. Once this decision is made, adding the information about the pregnancy serves to add complexity rather than being the sole focus of the consultation.

Conclusions

These guidelines add significantly to the literature on the management of depression during pregnancy and should be read by every clinician managing women of childbearing age. In the future, we hope that women will be routinely screened for this disease during pregnancy and that multiple treatment options will be available. Depression is a disabling illness that should not be overlooked in women simply because they are pregnant. However, a full risk/benefit decision-making model should be used when deciding with patients whether to initiate, continue, or discontinue antidepressants in the context of pregnancy.