Major Depressive Disorder (MDD) in Pregnant Population

As future Primary Mental Health Nurse Practitioners (PMHNP), it is critical to understand the different characteristics we may face when choosing a course of treatment for a client. Pregnancy, breastfeeding, and age are a few characteristics that we may encounter along the way. However, understanding the pharmacological and nonpharmacological therapies can be essential in the clients’ outcomes. This discussion aims to identify a specific population and disorder of the DSM-5, along with describing one FDA-approved medication, one non-FDA-approved medication, and one nonpharmacological intervention used to treat the particular disorder.  

Treating a Specific Population

I have chosen to treat Major Depressive Disorder (MDD) in the pregnancy population as my specific characteristic of a client. I will identify the appropriate course of treatment when prescribing an FDA-approved medication, non-FDA-approved medication, and a nonpharmacological intervention before deciding on any treatment plan. It is essential to know what trimester the client is in and provide a behavioral risk assessment to measure the level of depression. One of the tools that are commonly used is The Behavioral Health Risk Assessment (for pregnant women) (BHRA-CH) Maternal Care (CMS, 2021).

If a client becomes pregnant and is currently on an antidepressant for MDD, experts agree that keeping the current regimen is the safest for the mother (Mesches et al., 2020). Most antidepressants, such as SSRIs, have been found not to have any physical effects on the mother or baby (Mesches et al., 2020). However, untreated MDD could pose more risk for a developing fetus (Mesches et al., 2020). A client who is depressed is more likely not to seek good prenatal care and is more likely to engage in unhealthy behaviors such as smoking, drinking alcohol, and substance abuse (Mesches et al., 2020).      

FDA Approved Medication

Sertraline is an FDA-approved medication, a selective serotonin reuptake inhibitor (SSRI) that works in the brain and treats MDD and generalized anxiety disorder (GAD). However, with any medication, there are risks and benefits. The main advantage of this medication is that the FDA has approved it. Research shows that the continuation of this medication, even if the client is pregnant, outweighs the risks of discontinuing the drug. Sertraline is also a medication that can be continued while breastfeeding and is shown to have insufficient evidence of low birth weight and no evidence of any cardiac malformations (Behling & Bloch, 2021). Discontinuing this medication would pose the threat of the mother/client having persistent depression into the postnatal period threatening the attachment period that the mother and baby share right after birth (Behling & Bloch, 2021).         

Non-FDA Approved Medication

Fluvoxamine is also an SSRI but is prescribed as an FDA non-approved medication known as an off-label drug to treat MDD. These medications’ main risk is that it is not FDA approved for pregnant women being treated for MDD, along with the risk of cardiac malformation in the infant (Gao et al., 2017). Even though this risk is low, it still needs to be discussed with the client to see if this is something she wants to do. The benefit of this medication is that the client can still treat her MDD during her pregnancy and does not risk any detrimental breakthroughs of depression (Gao et al., 2017).    

Nonpharmacological Intervention

There are quite a few nonpharmacological interventions available if the client/mother decides to forego her antidepressants during pregnancy, such as electroconvulsive therapy (ECT) (Ward et al., 2018). This nonpharmacological option can be used for MDD clients in which medications are not working and clients that are pregnant or for those clients that may decide they don’t want to take antidepressants. This form of therapy sends electrical currents to the brain affecting neurons and chemicals. One of the main benefits of this therapy is that it is safe for both the client and baby and does not ingest any medications that could potentially be harmful (Ward et al., 2018). However, an adverse risk to this option and preceding the pharmacological intervention is the chance of ECT not working and no longe3r having the medication in the client’s system, exposing them to even more depression (Ward et al., 2018).      

Conclusion

As future PMHNP, we must understand that the treatment plans we decide on will always affect the outcomes of a client. We need to consider their feelings and unique characteristics that may distinguish them as patients, such as age and pregnancy. These important characteristics will help us decide what pharmacological and nonpharmacological interventions to treat our patients with and have a positive outcome. 

References

Behling, E., & Bloch, M. H. (2021). Don’t forget, untreated maternal depression poses health risks to the child, too. Biological Psychiatry90(4), 212–213. https://doi.org/10.1016/j.biopsych.2021.06.010

CMS. (2021). Behavioral Health Risks Screening Tool – Virginia. Centers for Medicare and Medicaid Services. Retrieved January 24, 2022, from https://www.dmas.virginia.gov/media/1489/provider-tool.pdf

Gao, S.-Y., Wu, Q.-J., Zhang, T.-N., Shen, Z.-Q., Liu, C.-X., Xu, X., Ji, C., & Zhao, Y.-H. (2017). Fluoxetine and congenital malformations: A systematic review and meta-analysis of cohort studies. British Journal of Clinical Pharmacology83(10), 2134–2147. https://doi.org/10.1111/bcp.13321

Mesches, G. A., Wisner, K. L., & Betcher, H. K. (2020). A common clinical conundrum: Antidepressant treatment of depression in pregnant women. Seminars in Perinatology44(3), 1–4. https://doi.org/10.1016/j.semperi.2020.151229

Ward, H. B., Fromson, J. A., Cooper, J. J., De Oliveira, G., & Almeida, M. (2018). Recommendations for the use of ECT in pregnancy: Literature review and proposed Clinical Protocol. Archives of Women’s Mental Health21(6), 715–722. https://doi.org/10.1007/s00737-018-0851-0

I chose to focus on Major Depressive Disorder(MDD) and pregnancy because MDD is one of the most common psychiatric illnesses. In addition, pregnancy can exacerbate MDD, especially regarding Post-Partum Depression.

FDA-approved medication

The FDA-approved medication for the treatment of Major Depressive Disorder(MDD) that I chose was Zoloft(sertraline) in the patient population of pregnancy. There are risks associated with Zoloft during pregnancy and breastfeeding. Zoloft is listed as a Category B medication during pregnancy. However, the incidence of Teratogenic effects is not detectable in animal-based studies, and human-based observational studies have shown no teratogenic effects. There is a risk of serotonin syndrome to the infant while breastfeeding and SSRI discontinuation syndrome in the infant if not breastfeeding(Armstrong, 2007).

The risks associated with Zoloft are primary in the third trimester and the breastfeeding phase. Therefore, the provider should be aware of the risks in the third trimester and breastfeeding. The Risk/Benefit depends on the mother’s severity of depression and her response to Zoloft previously. MDD can be quite serious, with increased risks of gestational diabetes and HTN associated with low activity levels. The clinical guidelines consist of monitoring and enrollment in the National Pregnancy Registry(Armstrong, 2007).

Off-label FDA-approved medication

The off-label FDA-approved medication for the treatment of Major Depressive Disorder I chose was Risperdal(risperidone). Risperidone can be used as an adjunct with an SSRI and an SSNI for those patients who don’t respond to a high dose of an anti-depressant. It is not FDA-approved as an anti-depressant adjunct. However, Risperdal is one of the oldest and least expensive second-generation antipsychotics (SgA). Therefore, the risk of teratogenicity is not expected. Risperdal is currently listed as a Category C medication. The risks associated with Risperdal are chiefly neo-natal Extra Pyramidal Symptoms and general antipsychotic withdrawal symptoms related to SgA’s. The risk analysis would primarily consist of the patient’s psychotic features with the depression and the current severity of the depression in the mother. Risperdal has many of the same warnings regarding SgA’s during pregnancy as other medication in the class(Cohen et al., 2016).

Therapeutic Intervention

Cognitive-based therapy(CBT) is the most logical starting point for therapeutic intervention. CBT is widely available, and the practitioners are fairly easy to find. However, the logistics of attending and planning therapy should not be ignored as pregnant females will often have other children. This implies that pregnant females will often have time and financial constraints. Also, CBT can be modified for perinatal depression to deal with the post-partum mood and hormone changes preemptively. The term perinatal describes the time around birth when depression symptoms can appear or be exacerbated by hormone changes.

References

Armstrong, C. (2007). Clinical management guidelines for obstetrician-gynecologists use of psychiatric medications during pregnancy and lactation. Obstetrics & Gynecology7(3), 385–400. https://doi.org/10.1176/foc.7.3.foc385

Cohen, L. S., Viguera, A. C., McInerney, K. A., Freeman, M. P., Sosinsky, A. Z., Moustafa, D., Marfurt, S. P., Kwiatkowski, M. A., Murphy, S. K., Farrell, A. M., Chitayat, D., & Hernández-Díaz, S. (2016). Reproductive safety of second-generation antipsychotics: Current data from the Massachusetts General Hospital National Pregnancy Registry for atypical antipsychotics. American Journal of Psychiatry173(3), 263–270. https://doi.org/10.1176/appi.ajp.2015.15040506

Sockol, L. E. (2015). A systematic review of the efficacy of cognitive-behavioral therapy for treating and preventing perinatal depression. Journal of Affective Disorders177, 7–21. https://doi.org/10.1016/j.jad.2015.01.052

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