What is the recommended management of depression in pregnancy?

Management of Depression in Pregnancy

A stepped approach to treatment is recommended for depression during pregnancy, with psychotherapy as first-line for mild depression and consideration of antidepressants for moderate-to-severe depression or when psychotherapy is ineffective. 1

Initial Assessment and Non-Pharmacological Management

• Screen all pregnant women for depression using validated tools such as the Patient Health Questionnaire, Hospital Anxiety and Depression Scale, or Edinburgh Postnatal Depression Scale 2
• For mild depression with recent onset (≤2 weeks), begin with monitoring and encourage exercise and social support before initiating pharmacological treatment 1
• For mild depression that doesn't improve within two weeks or moderate-to-severe depression, evidence-based treatment should be offered 1
• Evidence-based psychotherapies, such as cognitive therapy, are roughly equally effective as antidepressants for treating depression and should be considered first-line treatment for mild-to-moderate depression 1

Pharmacological Management

When to Consider Antidepressants

Antidepressants may be appropriate for:

• Women with moderate-to-severe depression 1, 2
• Those with history of severe suicide attempts or severe depression who previously responded well to medication 1
• Women who have previously relapsed when discontinuing antidepressant treatment 1, 2
• Those who have tried psychotherapy without adequate symptom reduction 1
• Women who prefer antidepressant treatment over psychotherapy 1

Medication Selection

• SSRIs are the most commonly prescribed antidepressants for pregnant women 1
• Sertraline and paroxetine transfer to breast milk in lower concentrations than other antidepressants, making them preferred options during breastfeeding 1
• Caution with paroxetine: The FDA classified paroxetine as pregnancy category D in 2005 due to concerns about congenital cardiac malformations, although more recent evidence suggests no link between first-trimester antidepressant use and cardiac malformations 1, 2

Risks and Benefits Assessment

Risks of Untreated Depression

• Depression during pregnancy is associated with premature birth and decreased initiation of breastfeeding 1
• Untreated depression can lead to poor maternal self-care, increased substance use, and risk of postpartum depression 3
• Severe depression may increase risk of suicide attempts and poor pregnancy outcomes 3, 4

Potential Risks of Antidepressant Use

• Antidepressant use during pregnancy may increase risk of preterm delivery compared with untreated women who have depression 1
• The FDA revised its 2006 advisory on SSRI use after the 20th week of gestation in 2011, stating that conflicting findings make it unclear whether SSRIs during pregnancy cause persistent pulmonary hypertension of the newborn (PPHN) 1, 2
• A meta-analysis found a link between late pregnancy exposure to SSRIs and PPHN, with a number needed to harm of 286 to 351 1
• Neonatal behavioral syndrome (including restlessness, poor tone, respiratory distress) may occur in infants exposed to SSRIs late in pregnancy, but symptoms are usually brief and not serious 5, 3

Neurodevelopmental Outcomes

• Recent evidence provides reassurance that antidepressant use during pregnancy is unlikely to substantially increase the risk of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) 1, 2
• Studies have suggested associations between antidepressant use in pregnancy and lower Apgar scores, ADHD, and speech delay, although high-quality evidence is lacking 1

Clinical Decision-Making Algorithm

1. Assess severity of depression:

   • Mild with recent onset: Begin with non-pharmacological approaches 1
   • Moderate-to-severe or persistent mild: Consider pharmacotherapy 1, 2

2. Consider patient history:

   • Previous response to medication
   • History of relapse when discontinuing medication
   • Previous suicide attempts 1, 2

3. If medication is indicated:

   • Consider SSRIs as first-line (except paroxetine) 1, 6
   • For breastfeeding plans, consider sertraline as preferred option 1, 5

4. Monitor closely:

   • Regular assessment of depressive symptoms
   • Watch for medication side effects
   • Plan for delivery with neonatology awareness of medication exposure 3

Common Pitfalls and Caveats

• Abrupt discontinuation risk: Stopping antidepressants during pregnancy due to safety concerns without proper management can lead to relapse and increased suicide risk 3, 7
• Overestimating medication risks: The absolute risks of most antidepressants are small, and these risks must be weighed against the substantial risks of untreated depression 8
• Undertreatment: Depression during pregnancy is often underdiagnosed and undertreated due to concerns about medication safety 3
• Ignoring severity: Treatment decisions should be guided by depression severity - mild cases may respond well to non-pharmacological approaches, while moderate-to-severe cases often require medication 1, 2