Protocols for High-Risk Pregnancies: Depression

A snapshot of Protocol 3 from the 6th edition of Protocols for High-Risk Pregnancies: An Evidence-Based Approach







Author: Kimberly Yonkers, Departments of Psychiatry; Obstetrics, Gynecology and Reproductive Sciences; and Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut

Synopsis: In this protocol, Dr Yonkers reviews the pathophysiology, diagnosis, management, and follow up of depression. Included is perspective on the role of pharmacotherapy and choice of drug, with consideration of teratogenic risks.

At some time in their lives, 1 in 5 women will suffer from depression and the risk is greatest during a woman’s reproductive years. Maternal depression As Dr Yonkers notes, the risk of birth defects associated with antidepressants is small but ob/gyns need to balance the potential for these adverse effects with the benefits of preventing a major depressive episode in a pregnant woman. Some research suggests that maternal depression may be associated with particular perinatal complications.

Key Messages:

• The pathophysiology of depression is unknown but biology may determine a woman’s underlying risk of having the condition.

• A diagnosis of depression requires that a patient have at least 5 of 9 symptoms described in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. The symptoms in DSM-5 range from depressed mood and diminished interest to decreased concentration and recurrent thoughts of suicide.

• Management of depression during pregnancy varies, depending on whether a woman’s illness is unipolar or bipolar. Regardless, consultation with a psychotherapist may be appropriate.

• Treatment with a mood stabilizer and an antidepressant is recommended for bipolar disorder. During pregnancy, first- and second-generation antipsychotics are associated with a lower risk of birth defects than anticonvulsants and lithium, and they have good mood stabilizing properties.

• Antidepressants can be prescribed for women with unipolar depression that does not respond adequately to psychotherapy or bipolar depression that does not respond to mood stabilizers.

• Selective serotonin reuptake inhibitors and bupropion are the antidepressants of choice for women of reproductive age because of their safety profile. Paroxetine should not be prescribed during the first trimester because it is associated with fetal cardiac malformations.

• Patients to whom pharmacotherapy is prescribed should be monitored for adverse effects and psychiatric status. A second visit 2 weeks later is recommended, and visits at 1-month intervals thereafter.  It may take 6 to 8 weeks before a patient fully responds to treatment.

READ the complete protocol on depression from Protocols for High-Risk Pregnancies: An Evidence-Based Approach, 6th Edition, edited by John T Queenan, Catherine Y Spong, and Charles J Lockwood, now at:

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