Options for pharmacologic management of perinatal depression

The above table lists options for medication management of perinatal depression. When trying to determine which antidepressants should be initiated, several factors should be considered.

In women who have a history of depression that was successfully treated with a specific antidepressant, consideration should be given to restarting that same medication, instead of automatically initiating an SSRI. This is especially important in women who have a history of significant depression or anxiety that failed to respond to multiple medications. Although much of the data available are related to SSRI use in pregnancy, there is sufficient research on other classes of antidepressants such as serotonin-norepinephrine reuptake inhibitors and atypical antidepressants to show adequate safety data.^1-3 Again, the goal is to help the woman achieve remission as quickly and effectively as possible.

Of SSRIs, fluoxetine and sertraline have been extensively studied and escitalopram and citalopram have also been well studied, all of which are believed to be safe in pregnancy.⁴ Paroxetine, also an SSRI, has been shown in some studies to possibly increase risk of cardiac malformations, however, in further study, the risk has been shown to be negligible.⁴ Despite this, unless necessary, other SSRIs should be initiated instead of paroxetine.

In women who are naïve to antidepressants, initiation of sertraline should be considered as first line because of the lack of active metabolites and 24-hour half-life. Medications should be titrated serially to achieve remission of symptoms. All antidepressants take 4 to 6 weeks to show effect, thus it is important to recognize symptoms and diagnose the mood disorder so that treatment can be initiated as early as possible. Importantly, before prescribing an antidepressant, women should always be screened for bipolar disorder because using these drugs alone in such patients could precipitate a manic episode.⁵

It bears mentioning that women with a history of depression who are on psychiatric medications at the time of pregnancy confirmation should not stop medications without speaking first to their psychiatrist or obstetrician. 

Finally, care should be given to adolescent and young adult women when beginning antidepressants due to the black box warning showing possible increased risk of suicidality in this age group with initiation of SSRIs.⁶ It is imperative that all women- especially younger women-be seen within 1 to 2 weeks of medication initiation for follow-up. In addition, they should all be counselled to notify the clinician about any adverse effects associated with initiation of pharmacologic therapy.

References:

• Yaris F, Kadioglu M, Kesim M, Ulku C, Yaris E, Kalyoncu NI, et al. Newer antidepressants in pregnancy: prospective outcome of a case series. Reprod Toxicol 2004;19:235–8.

• Kesim M, Yaris F, Kadioglu M, Yaris E, Kalyoncu NI, Ulku C. Mirtazapine use in two pregnant women: is it safe? Teratology. 2002;66:204.

• Chun–Fai–Chan B, Koren G, Fayez I, Kalra S, Voyer–Lavigne S, Boshier A, et al. Pregnancy outcome of women exposed to bupropion during pregnancy: a prospective comparative study. Am J Obstet Gynecol. 2005;192:932-936. 

• Use of psychiatric medications during pregnancy and lactation. ACOG Practice Bulletin No. 92. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2008;111:1001-1020.

• Benvenuti A, Rucci P, Miniati M, et al. Treatment-emergent mania/hypomania in unipolar patients. Bipolar Disord. 2008;10(6):726-732. 

• Stone M, Laughren T, Jones M, et al. Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration. BMJ. 2009;339