Depression occurs in about 14–23% of all pregnant women. It is essential that we know how to make the diagnoses, when to treat, and the safety profile of the various drugs in managing this disorder. A recent landmark review was published by The American College of Obstetrics and Gynecology and the American Psychiatric Association that reviews the current guidelines.
Should I take an antidepressants if I am thinking of becoming pregnant?
Women with minimal or no symptoms for 6 months prior to conception, should contemplate tapering and discontinuing medication before conception. Behavioral therapy treatments can be used instead of medication.
Women with moderate to severe symptoms on medication should have their psychiatrist continue and optimize their medication prior to conception. The safety profile of the medications used should be carefully evaluated. Newer medications for depression and psychosis should be avoided if safety profile is not available.
Other conditions such as substance abuse, anxiety disorders, and eating disorders should be addressed at the same time.
What is the relationship between maternal depression and pregnancy outcomes?
Results from studies on miscarriage, growth effects, preterm births, and developmental delay with depression and use of antidepressant medication is severely limited due to poor studies and lack of consistency in conclusions. However, there was some evidence of an association of maternal depression and increased irritability, less attentiveness and activity, and fewer facial expressions in the newborn infant.
What is the safety profile of some of the commonly used antidepressant medication?
Tricyclic antidepressants-(Elavil, Norpramin, Pamelor, Aventyl, Anafranil, Tofranil, Evadyne)
Most studies have shown no association between the use of the tricyclic antidepressants and structural malformations. There was an increased association with newborn complications such as jitteriness, irritability, and occasionally convulsions.
Serotonin reuptake inhibitors (examples include Prozac, Celexa, Paxil, and Zoloft)
Some studies have shown a higher risk of cardiac malformations when SSRI’s were used during the first trimester, although the risk is considered very low and does not yet warrant the recommendations that women should not take these drugs. Combinations of different SSRI’s seem to have an even greater risk profile. However, other factors might be contributing to the results including obesity, diabetes, alcohol, and tobacco use. Some studies have shown evidence of rapid breathing, low sugar, temperature instability, irritability, weak cry, lower Apgar scores, and seizures in infants exposed to SSRI’s, especially in late pregnancy. Especially concerning were some reports of persistent pulmonary hypertension and respiratory distress. This can result in right heart failure.
Other antidepressants (Wellbutrin and Zyban, Effexor, Cymbalta, Remeron)
Fewer studies have been done on these agents but no increased risk of congenital anomalies or stillbirths have been found. There was a higher rate of newborn symptoms such as respiratory problems, low Apgar scores,hypoglycemia, and neonatal convulsions compared to women on no medications.
Electroconvulsive therapy
Severe depression that is unresponsive to medication can be treat with electroconvulsive therapy and does not harm the mother or the fetus.
Summary:
In conclusion, treatment of depression in pregnancy is based upon the risk of untreated mental illness in the mother versus risk factors to the fetus with the use of medication. The approach to decision making should be based on multiple factors including the severity of the disease, risk of relapse by stopping medications, response to therapy, social support, and recommendations on the part of the psychiatrist.
