Psychiatric illness during pregnancy
Early detection, individualized care can promote health for mother and infant
- keep the medication regimen simple and at the lowest effective dose
- use monotherapy when appropriate
- if possible, do not change medications during pregnancy.
When considering pharmacotherapy, evaluate each woman’s risk for disease exacerbation and consequences for pregnancy and neonatal outcomes, and ask the woman how she views reproductive risk vs disease benefit.
Developing fetuses are exposed to either the effects of the mother’s untreated mental illness or the medication.26 A recent study comparing birth and neonatal outcomes among women with untreated depression vs those taking selective serotonin reuptake inhibitors (SSRIs) found similar adverse outcomes.27 Babies continously exposed to either prenatal depression or SSRIs were more likely to be born prematurely, but partial exposure to either condition did not increase this risk.27 In addition, women who were not taking SSRIs had more depressive symptoms and more trouble functioning, which can interfere with bonding between mother and baby, both in-utero and postpartum.6,27 Neither SSRIs nor depression exposure increased risk for minor physical anomalies.27
A careful process of informed consent and documentation is essential when prescribing medications during pregnancy. Women should understand the risks of pharmacotherapy as well as the risks of undertreated illness.
Electroconvulsive therapy can safely help pregnant women with treatment-resistant, life-threatening, or psychotic depression.28,29
Table 2
Risk factors for perinatal psychopathology
| Pregnancy during adolescence |
| Previous diagnosis of depression, anxiety, psychosis, or bipolar disorder |
| Trauma history, including physical, emotional, or sexual abuse |
| Current or past substance abuse/dependence, including cigarette smoking |
| Lack of social support |
| Single parenthood |
| Low socioeconomic status |
| History of sexual assault or domestic violence |
| Unstable home environment |
| Stopping antidepressants during pregnancy |
| Financial problems |
| Ambivalence about pregnancy |
| Source: References 5,22 |
Psychotherapy. The American College of Obstetricians and Gynecologists treatment guidelines22 favor psychotherapy over medication for women with mild depressive symptoms and no loss of function, suicidality, or psychotic experiences; pharmacotherapy is suggested for women who have moderate to severely impaired functioning, recurrent depressive symptoms, or suicidal thinking (Table 3).22
Interpersonal psychotherapy or cognitive-behavioral therapy can be safe and effective during pregnancy.30,31 Other psychotherapeutic modalities and alternative/complementary treatments offer potential benefit without substantial risk, and could help prevent relapse when discontinuing mood stabilizers or antidepressants after conception (Box 2).32-35
Table 3
ACOG guidelines for treating depression during pregnancy
| Women who are thinking about getting pregnant |
| For women on medication with mild or no symptoms for ≥6 months, it may be appropriate to taper and discontinue medication before becoming pregnant |
| Medication discontinuation may not be appropriate in women with a history of severe, recurrent depression or who have psychosis, bipolar disorder, other psychiatric illness requiring medication, or a history of suicide attempts |
| Pregnant women currently taking medication for depression |
| Psychiatrically stable women who prefer to stay on medication may be able to do so after consultation between their psychiatrist and obstetrician to discuss risks and benefits |
| Women who want to discontinue medication may attempt to taper and discontinue if they are not experiencing symptoms, depending on their psychiatric history. Women with a history of recurrent depression are at a high risk of relapse if medication is discontinued |
| Women with recurrent depression or who have symptoms despite medication may benefit from psychotherapy to replace or augment medication |
| Women with severe depression (with suicide attempts, functional incapacitation, or weight loss) should remain on medication. If a patient refuses medication, alternative treatment and monitoring should be in place, preferably before discontinuation |
| Pregnant and not currently on medication for depression |
| Psychotherapy may be beneficial for women who prefer to avoid antidepressants |
| For women who want to take medication, risks and benefits of treatment choices should be evaluated and discussed, including factors such as stage of gestation, symptoms, history of depression, and other conditions and circumstances (eg, smoking, difficulty gaining weight) |
| All pregnant women |
| Regardless of circumstances, a woman with suicidal or psychotic symptoms should immediately see a psychiatrist |
| ACOG: American College of Obstetricians and Gynecologists Source: Reference 22 |
Mind-body approaches such as mindfulness-based stress reduction, yoga, and progressive relaxation and supplements such as fish oil may be good adjuncts to psychotherapy. Many pregnant women prefer mindfulness yoga to other mind-body techniques.32 A pilot study found that mindfulness yoga significantly decreased depressive symptoms and increased maternal-fetal attachment, particularly in mildly depressed women.33 For women who do not wish to engage in traditional treatments, alternative approaches such as progressive relaxation are easily taught and can help reduce depressive symptoms.34 Regular exercise may improve self-esteem and reduce symptoms of depression and anxiety in pregnant women.35
CASE CONTINUED: Healthy baby boy
Ms. A either doesn’t show up or cancels her weekly appointments about once a month, but seems to be making progress. Her therapist makes accommodations for Ms. A, such as offering childcare in an adjacent room during sessions, conducting brief sessions by phone when Ms. A is unable to come to the clinic, and helping her enroll in the state’s Maternal Infant Health Program. Ms. A’s therapist has referred her to a specialized OB clinic that can manage her pain medication and monitor for signs of abuse and keeps in regular contact with her obstetrician.
