Depression and pregnancy

Depression is one of the most common mental health diagnoses.  Patient who are pregnant and diagnosed with depression face an increased risk during their pregnancy for spontaneous abortion, low birth weight, and preterm delivery just to name a few complications (Mitchel & Goodman, 2018).  These same risks are also associated with the medications used to treat depression during pregnancy. 

Pregnancy is a time in a patient’s life where specific care needs to be taken when prescribing medications.  Some women stop virtually all medications for fear of the side effects to themselves and their babies.  While some medications are supposed to be safe to take during pregnancy, others may cause significant complications.  If a patient is pregnant and questions regarding safety need to be addressed, it would be best practice to involve the patient’s obstetrician in the discussion to determine the best plan of care.  Studies have shown that patients with poorly treated depression during the perinatal period have significantly more complications related to bonding between mother and child and emotional problems for both (Mitchel & Goodman, 2018).

In one study conducted by the American College of Obstetricians and Gynecologists (ACOG), they found that 84% of the doctors in the survey prescribed some type of Selective Serotonin Reuptake Inhibitor (SSRI) to pregnant patients while 31.7% of the doctors prescribed non-SSRI’s (Taouk, Matterson Stark, & Schulkin, 2018).  As a provider prescribing for a pregnant woman one option would be sertraline (Zoloft).  This medication is listed as a Class C for pregnancy meaning animals showed reproductive complications, but the benefits may outweigh the risks.  Zoloft was prescribed by 84% of the Ob-gyn doctors in the ACOG study.  This medication was often used as the first line treatment for depression. According to the Federal Drug Administration (FDA), there are currently no adequate and well controlled studies regarding SSRI treatment in pregnant women.

For an alternative treatment method for depression, Cognitive Behavioral Therapy (CBT) has been recommended by the ACOG in a 2009 study that is still being used on the FDA’s website as an alternative (Yonkers, Oberlander, Stewart, & Wisner, 2009).  CBT has many uses in treatment with mental health patients especially depression. While the FDA recommends that treatment for depression not be altered by the provider, the patient must know the risks involved by continuing their current medication regimen.  Since the FDA does not have specific approvals for SSRI’s during pregnancy, I would not prescribe an off-label medication used to treat depression.  Most other psychiatric medications that may help with depression such as mood stabilizers often require additional medications in conjunctions (such as a SSRI).  The FDA suggests women do not take anti-depressants unless they have determined the benefits outweigh the risks.

There are companies who offer genetic testing to help determine the most appropriate course of action when prescribing psychiatric medications.  If the medications used to treat pregnant women are in a part of the report that states the medication is a poor choice based off the genetic makeup of the patient and the medication itself, then the medication shouldn’t be prescribed.  The patient will not receive a benefit from the medication per the genetic report, so the risk to the fetus shouldn’t be increased by trialing medications. In order to determine the best course of action a thorough description of potential complications, treatment options (medications, therapy, etc), and collaboration with the patient, Ob-gyn, and mental health provider needs to occur.  If the patient understand the risks and complications and is still willing to treat depression with an appropriate medication then that decision should be honored.

Mitchell, J., & Goodman, J. (2018). Comparative effects of antidepressant medications and untreated major depression on pregnancy outcomes: a systematic review. Archives of Women’s Mental Health, 21(5), 505.

Taouk, L. H., Matteson, K. A., Stark, L. M., & Schulkin, J. (2018). Prenatal depression screening and antidepressant prescription: obstetrician-gynecologists’ practices, opinions, and interpretation of evidence. Archives of Women’s Mental Health, 21(1), 85–91.

Yonkers, K., Oberlander, T., Stewart, D., & Wisner, K. (2009). The management of depression during pregnancy: A report from the American Psychiatric Association and the American College of Obstetricians and gynecologists. Obstetrics & Gynecology, 114(3), 703–713. https://doi.org/10.1097/aog.0b013e3181ba0632

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