Depression in pregnancy: When doing nothing is not an option

February 1, 2008

How do you and your depressed patients walk that fine line between the risks of taking-or not taking-antidepressants during pregnancy? Which drugs or alternate therapies seem safest? An expert cautions that maternal and fetal risks of untreated mental illness-ranging from spontaneous abortion to suicide-may outweigh the risks of antidepressants.

Key Points

Treating depression during pregnancy is just as essential as treating epilepsy or hypertension.

Antenatal depression affects the health and well-being of the mother, baby, and family. And although many women, their partners, and even physicians think they can "tough it out" during pregnancy, untreated depression is far from a benign illness.1 A depressed woman is more likely not to comply with her prenatal care, to self-medicate with tobacco, alcohol, and illicit drugs, and to commit suicide, all of which underscore a pressing need for appropriate treatment. She may also consider terminating her pregnancy-even when it was planned (Table 1).2

Which patients are most at risk?

Women with a history of major depression are at high risk for relapse during pregnancy, especially if they discontinue medications.6 In a study of 201 women who were not depressed at conception, 68% of those who discontinued their medication during pregnancy relapsed, compared with only 26% of those who continued; the hazard ratio was 5.0 (95% CI, 2.8–9.1). And because even staying on the drugs doesn't completely protect pregnant patients against relapse, these women require close monitoring.7,8

Identifying depression in pregnancy

Since there's no separate category for perinatal depression, be aware of the American Psychiatric Association criteria for diagnosing major depression, which requires a patient to have experienced at least five of nine possible symptoms over the previous 2 weeks.9 To make the diagnosis, one of these five must be either:

1. a depressed (or low) mood nearly all-day long, nearly daily, or
2. sharply diminished interest or pleasure in the majority of activities with that same frequency.

The other seven symptoms to look for, which should be occurring nearly daily, are:
3. a decrease or increase in appetite (or a monthly weight change-up or down without dieting-of at least 5% of her body weight);
4. sleeping too much or trouble sleeping;
5. nonsubjective psychomotor agitation or retardation;
6. energy loss or fatigue;
7. lessened ability to concentrate or think, or difficulty with decision-making;
8. feeling worthless, or overly or inappropriately guilty
9. attempting, specifically planning, or thinking about suicide, or having recurring thoughts of death.9

Depression identified within the first postpartum year is considered postpartum depression.1 Clinicians and patients often misattribute the symptoms of depression such as insomnia, lack of energy, and changes in appetite and weight, to the expected changes of pregnancy. Sad, blue, hopeless, or helpless mood are symptoms of a possible mood disorder, and thinking about suicide is never normal. Women feel guilty about being depressed during pregnancy, so many suffer in silence. When a woman does complain, she should be evaluated.1