Guidelines for Treating Depression During Pregnancy

The American Psychiatric Association (APA), in conjunction with the American College of Obstetricians and Gynecologists (ACOG), has released, for psychiatrists and OBGYNs, a set of guidelines for managing depression during pregnancy.

Based on “an extensive review of existing research,” the guidelines issued by the APA and ACOG discuss four groups: women who are thinking about getting pregnant, pregnant women who are currently on medication for depression, women who are pregnant and not currently on medication for depression, and all women who are pregnant. The goal of the guidelines, according to the researchers, is to enable physicians to more effectively treat depression in pregnant women and reduce the negative side effects to the newborns that may result from anti-depressant medications.

According to the researchers, some cases of mild or moderate depression can be treated with psychotherapy alone, which the researchers add may reduce or eliminate side effects, of both untreated depression and antidepressant medication, for both the mother and the unborn baby. Pregnant women who are depressed but not treated are more likely to have poor prenatal care and pregnancy complications, such as nausea, vomiting, and preeclampsia; this population is also at a greater risk for drug, alcohol, and nicotine use, according to the researchers. Although the researchers say that “available research still leaves some questions unanswered” in regards to infant health, fetal malformations, cardiac defects, pulmonary hypertension, and reduced birth weight have all been linked to use of antidepressant medication by mothers during the pregnancy.

“Depression in pregnant women often goes unrecognized and untreated in part because of concerns about the safety of treating women during pregnancy,” said lead author Kimberly Ann Yonkers, MD, Yale University associate professor of psychiatry and obstetrics, gynecology and reproductive sciences. “It is our hope that this will be a resource to clinicians who care for pregnant women who have or are at risk of developing major depressive disorder.”

Results of the study were published in the journals Obstetrics and Gynecology and General Hospital Psychiatry.

Below are the guidelines, as they appear in the report:

“Women thinking about getting pregnant

• For women on medication with mild or no symptoms for six months or longer, it may be appropriate to taper and discontinue medication before becoming pregnant.

• Medication discontinuation may not be appropriate in women with a history of severe, recurrent depression (or who have psychosis, bipolar disorder, other psychiatric illness requiring medication, or a history of suicide attempts). • Women with suicidal or acute psychotic symptoms should be referred to a psychiatrist for aggressive treatment.

Pregnant women currently on medication for depression

• Psychiatrically stable women who prefer to stay on medication may be able to do so after consultation between their psychiatrist and ob-gyn to discuss risks and benefits.

• Women who would like to discontinue medication may attempt medication tapering and discontinuation if they are not experiencing symptoms, depending on their psychiatric history. Women with a history of recurrent depression are at a high risk of relapse if medication is discontinued.

• Women with recurrent depression or who have symptoms despite their medication may benefit from psychotherapy to replace or augment medication.

• Women with severe depression (with suicide attempts, functional incapacitation, or weight loss) should remain on medication. If a patient refuses medication, alternative treatment and monitoring should be in place, preferably before discontinuation.

Pregnant and not currently on medication for depression

• Psychotherapy may be beneficial in women who prefer to avoid antidepressant medication.

• For women who prefer taking medication, risks and benefits of treatment choices should be evaluated and discussed, including factors such as stage of gestation, symptoms, history of depression, and other conditions and circumstances (eg, a smoker, difficulty gaining weight).

All pregnant women

• Regardless of circumstances, a woman with suicidal or psychotic symptoms should immediately see a psychiatrist for treatment.”