It has been estimated that between 14% and 23% of pregnant women will experience depressive symptoms during their pregnancy. An investigation published in 2003 reported that about 13% of women take an antidepressant at some time during their pregnancy. “Depression in pregnant women frequently goes unrecognized and untreated for a host of reasons, including concerns about the safety of some treatments for pregnant patients and their offspring,” says Kimberly A. Yonkers, MD. “There may be risks associated with both untreated depression and the use of antidepressants that can complicate treatment decisions.”
A New Review
An evidence-based report from the American Psychiatric Association (APA) and the American College of Obstetricians and Gynecologists (ACOG) has been published to assist clinicians and patients as they weigh the risks and benefits of various treatment options for depression during pregnancy. The APA and ACOG convened a work group consisting of clinical research experts within the fields of obstetrics and gynecology, psychiatry, and pediatrics, which critically evaluated and summarized information about risks associated with depression and the use of antidepressants during pregnancy. The resulting recommendations were published jointly in the September 2009 issue of Obstetrics & Gynecology and the September/October 2009 issue of General Hospital Psychiatry.
“Typically, OB-GYNs, nurse practitioners, and nurse midwives are the clinicians who most often see women who are pregnant,” says Dr. Yonkers. “They can be the first clinician to make a diagnosis of depression in some cases. Other times, they may be the first to observe depressive symptoms that are worsening. In the past, reproductive health practitioners have reported feeling ill-prepared to treat these patients because of the lack of evidence-based guidance. With the publication of these recommendations, our hope is that we’ll better inform providers about current research on various depression treatment methods and improve clinicians’ understanding and ability to help with decision making.”
Diagnostic Challenges & Consequences
Identifying depression in pregnant women can be difficult because depressive symptoms often mimic usual experiences of pregnancy. “Some symptoms of depression, including changes in mood, energy level, appetite, and cognition, are normative in pregnancy,” explains Dr. Yonkers. “When these symptoms present, clinicians should view them as a cue to ask additional questions. We must also consider the likelihood that patients may be reluctant to admit feelings of depression. There is a belief that women are supposed to be happy when they’re pregnant, so they may be embarrassed to admit that they aren’t. Other women may view their depressed feelings as a character flaw rather than an illness, or they may believe that depression will reflect negatively on their capability of being a good mother.”
Research has shown that depressive symptoms and use of antidepressant medications during pregnancy have been associated with negative consequences for newborns. Infants born to women with depression are at greater risk for irritability, less activity and attentiveness, and fewer facial expressions when compared with those born to mothers without depression. Depression during pregnancy is also associated with fetal growth changes and shorter gestation periods. Dr. Yonkers adds that some studies have linked fetal malformations, cardiac defects, pulmonary hypertension, and reduced birth weight to antidepressant use during pregnancy. “Furthermore, depressed women are more likely to have poor prenatal care and pregnancy complications (eg, nausea, vomiting, and preeclampsia) and to use drugs, alcohol, and nicotine,” she says.
Highlighting Key Recommendations
According to the APA/ACOG report, some patients with mild-to-moderate depression can be treated with psychotherapy alone or in combination with medication. “There is no one-size-fits-all approach for managing depression during pregnancy,” Dr. Yonkers says. “Management approaches should depend on specific scenarios, patient characteristics, and severity of depression. The APA/ACOG report provides algorithms to help clinicians during their care of these women. It should be noted that there are more ways to intervene than to simply medicate or do nothing. Pregnant women with severe recurrent depression should be considered for some sort of treatment, be it psychological, medical, or both.”
One of the key recommendations of the APA/ACOG report is that there needs to be ongoing consultation between OB-GYNs, psychiatrists, and other healthcare providers during pregnancy (Figure). “A collaborative approach is paramount,” says Dr. Yonkers. “The more communication there is within this triad of providers, the better. We should seek to form a united front when dealing with a severe depressive disorder in this patient group.”
Physicians and providers should remember that women taking antidepressants prior to pregnancy received these medications for good reason, says Dr. Yonkers. “As providers, we can’t only look at one part of the picture in isolation and simply take all patients off antidepressants. We need to recognize that our treatment strategies and decisions may have profound effects during pregnancy.”
More Data Needed
Dr. Yonkers says that there is some existing research relating to antidepressant use in pregnancy, but more data are needed. “We have yet to adequately control for other factors that may influence birth outcomes, including maternal illness or health behaviors that can adversely affect pregnancy,” she says. “Few studies of antidepressants and birth outcomes assessed the mothers’ psychiatric condition. Confounding factors that influence birth outcomes—poor prenatal care and drug, alcohol, and nicotine use—are often not controlled in studies. Our recommendations may be utilized as a guide to foster more in-depth research. In the meantime, our hope is that they are used as a resource when caring for pregnant women who have or are at risk of developing major depressive disorder.”
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;114:703-713. Available at: http://journals.lww.com/greenjournal/Citation/2009/09000/The_Management_of_Depression_During_Pregnancy__A.44.aspx
Smith MV, Shao L, Howell H, Wang H, Poschman K, Yonkers KA. Success of mental health referral among pregnant and postpartum women with psychiatric distress. Gen Hosp Psychiatry. 2009;31:155-162.
Yonkers KA. Parsing risk for the use of selective serotonin reuptake inhibitors in pregnancy. Am J Psychiatry. 2009;166:268-270.
Yonkers KA, Smith MV, Lin H, Howell HB, Shao L, Rosenheck RA. Depression screening of perinatal women: an evaluation of the healthy start depression initiative. Psychiatr Serv. 2009;60:322-328.