Depression is a major health concern worldwide, and is the second leading cause of disability for people of reproductive age (15 to 44 years), according to the World Health Organization. Women experience depression two to three times more frequently than men. Depression can be devastating for these women in general, but it can lead to significant consequences when experienced before and during pregnancy. A new report, published jointly by the American Psychiatric Association (APA) and the American College of Obstetrics and Gynecology (ACOG), evaluates and summarizes the risks associated with depression and antidepressant therapy during pregnancy, and offers new guidelines for treatment decisions. On the whole, the report advises that many women consider discontinuing therapy with antidepressants before and during pregnancy.

Increasing attention has been paid to postpartum depression (PPD) in recent years. It is estimated that up to 16% of women will experience symptoms of depression in the first year after giving birth. PPD carries considerable emotional, physical, and psychological consequences for the mother and the child, but many researchers and clinicians now suggest than antenatal depression (depression during pregnancy) might be even more problematic. Nearly one-quarter of women experience antenatal depression, though maternal depression (both in the pre- and postnatal periods) is likely underdiagnosed. Maternal depression can lead to poor maternal self-care, increased risk-taking behavior, and poor pregnancy outcomes, including pre-eclampsia, birth difficulties for both mother and child, increased risk for PPD, and reduced breastfeeding. For the newborn, maternal depression can lead to lower APGAR (American Pediatric Gross Assessment Record) scores at birth, failure to thrive, and poor physical, emotional, and behavioral development. However, the interplay among these factors is unclear and a combination of factors likely influences maternal and child outcomes; while maternal depression does influence infant outcomes, poor infant outcomes can lead to maternal depression.

Signs and symptoms associated with antenatal depression are the same as those for depression in the general population: depressed mood, anhedonia, low self esteem, changes in sleep or appetite, decreased energy, and decreased concentration. The diagnosis of antenatal depression can be difficult, since there are no specific diagnostic criteria for depression during pregnancy; also, the normal symptoms of pregnancy overlap with symptoms of depression, making identification of depression problematic. Women and clinicians often attribute fatigue, decreased energy, appetite changes, and altered concentration to a normal, healthy pregnancy rather than a depressive disorder. On the other hand, researchers or clinicians who rely on questionnaires assessing somatic symptoms during pregnancy may overdiagnose depressive disorders in pregnant women. The risk factors for antenatal depression involve genetic and environmental factors. A genetic predisposition to depression can be affected by physical, mental, or emotional stress, infections, chronic diseases, medication use, lack of social support, low socioeconomic status, and poor nutrition.

Overall the APA/ACOG review reports that symptoms of depression and antidepressant use during pregnancy may be associated with preterm delivery, decreased fetal growth, and developmental changes in the child, but states that current research is inconclusive. Most studies were unable to control for confounding maternal factors such as maternal illness or high-risk health behaviors that affect pregnancy outcomes. However, due to the potentially damaging consequences of antidepressant use, the report recommends that some women who are pregnant or considering becoming pregnant taper or discontinue therapy to mitigate these risks.

Women who have experienced mild or no depressive symptoms for 6 months should consider discontinuing treatment with antidepressants before becoming pregnant. These women may benefit from psychotherapy during the treatment hiatus. Patients with suicidal or acute psychotic symptoms should optimize their therapy and be counseled to wait several months after adjusting therapy before conceiving. For these patients, the risks associated with untreated depressive symptoms often outweigh the potential harm to the unborn child. Antiepileptic agents, sometimes used to treat severe symptoms of depression and psychosis, should be avoided, if at all possible, during the first trimester of pregnancy owing to the risk of birth defects. Largely, women with depression before or during pregnancy should consider alternative treatment, according to the APA and ACOG, since reproductive safety information for antidepressants is lacking.

Close monitoring of pregnant women with depression is advised, and no treatment decision should be made without consulting a trained clinician. The risks and benefits of treatment — both to the mother and the child — should be weighed to ensure a safe and healthy pregnancy. Additional research is still needed to define the best possible treatment regimens for pregnant women.

References

Gavin, A., Holzman, C., Siefert, K., & Tian, Y. (2009). Maternal Depressive Symptoms, Depression, and Psychiatric Medication Use in Relation to Risk of Preterm Delivery Women’s Health Issues, 19 (5), 325-334 DOI: 10.1016/j.whi.2009.05.004

Leung, B., & Kaplan, B. (2009). Perinatal Depression: Prevalence, Risks, and the Nutrition Link—A Review of the Literature Journal of the American Dietetic Association, 109 (9), 1566-1575 DOI: 10.1016/j.jada.2009.06.368

Salisbury, A., Ponder, K., Padbury, J., & Lester, B. (2009). Fetal Effects of Psychoactive Drugs Clinics in Perinatology, 36 (3), 595-619 DOI: 10.1016/j.clp.2009.06.002

Yonkers, K. (2009). Parsing Risk for the Use of Selective Serotonin Reuptake Inhibitors in Pregnancy American Journal of Psychiatry, 166 (3), 268-270 DOI: 10.1176/appi.ajp.2008.08111703

Yonkers, K., Smith, M., Gotman, N., & Belanger, K. (2009). Typical somatic symptoms of pregnancy and their impact on a diagnosis of major depressive disorder??? General Hospital Psychiatry, 31 (4), 327-333 DOI: 10.1016/j.genhosppsych.2009.03.005

Yonkers, K., Wisner, K., Stewart, D., Oberlander, T., Dell, D., Stotland, N., Ramin, S., Chaudron, L., & Lockwood, C. (2009). The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists??? General Hospital Psychiatry, 31 (5), 403-413 DOI: 10.1016/j.genhosppsych.2009.04.003