Depression: Tailoring treatment to life stage

Restarting the serotonergic agent will relieve discontinuation symptoms rapidly. The drug then can be tapered slowly to avoid further adverse effects. Of course, this approach is not an option if the medication was stopped because of an allergic reaction. In these cases, reassure the patient that discontinuation symptoms are transient and not dangerous.

If rapid discontinuation is desired, a patient on the lower end of the dosage spectrum often can simply stop the drug, taking a low dose whenever she experiences discontinuation symptoms (e.g., taking 3 or 4 doses over a 10-day period).

TABLE 6

Serotonin discontinuation syndrome¹⁰

Medication during pregnancy

It is essential that Ob/Gyns develop a management plan that anticipates the possibility of a patient becoming pregnant while on antidepressant therapy.

Do not stop treatment reflexively if pregnancy occurs during therapy. Rather, discuss the risk-benefit ratio with the patient and her partner and establish a management plan while she is euthymic. Although no therapy is completely risk free, the goal is to limit exposure to both the illness and the treatment, and to help the patient decide which option poses the least risk. This discussion also should focus on protecting the patient’s mood after she gives birth, since her history of depression increases her risk for postpartum depression.¹¹

If the patient decides to continue medication during gestation (and, possibly, during lactation), continue the agent used before pregnancy. Changing medications simply increases the number of fetal exposures. If she instead opts to stop medication, rapidly tapering therapy over 3 to 5 days may decrease rebound and discontinuation symptoms.¹¹

There are more data on first-trimester exposure and neurobehavioral outcome for antidepressants than almost any other drug class. For most agents, the window of risk to fetal development occurs in the first trimester (TABLE 7). It is best to avoid agents during periods of highest risk, if this will not threaten the mother’s stability.¹¹ Note, however, that psychotropic medications (excluding anticonvulsants) have not been implicated in developmental issues with children.

TABLE 7

Windows and types of teratogenic risk for psychopharmacologic agents

Identifying and preventing postpartum depression

This syndrome occurs in 10% to 16% of adult women, and up to 26% of adolescent women.¹² Common symptoms include despondency, sleep disturbances and fatigue, irritability, anorexia, poor concentration, feelings of inadequacy, and ego-dystonic thoughts about harming the baby.

Women who develop mood symptoms during the current pregnancy, as well as those with a prepregnancy history of depressive disorders or previous postpartum mood symptoms, are at high risk for postpartum depression.² These mothers and their infants will benefit from prophylactic treatment, which should be started at delivery or during late pregnancy.

Medication during lactation. All psychotropic medications cross into breast milk, but in such small quantities that most researchers believe women can continue depression therapy during lactation. No adverse effect is commonly observed in infants who are exposed to antidepressant medication through breast milk.¹¹

This starkly contrasts to the potential adverse impact on both mother and infant when postpartum depression remains untreated.¹³

Alternative therapies

Botanical therapies have been widely used for mood and anxiety symptoms. Very high use is seen among the elderly and people with limited access to—or belief in—the mental health system.¹⁴ Note that data are insufficient to support the use of alternative therapies during pregnancy and lactation.

Patients should be warned not to use kava kava due to recent reports of sometimes-fatal liver toxicity. This substance has been used as an anxiolytic.¹⁵

Dr. Dell reports that she receives grant support from Berlex, GlaxoSmithKline, and Pfizer. She also serves on the speaker’s bureau for Berlex, GlaxoSmithKline, Lilly, Pfizer, TAP, and Wyeth-Ayerst and is a consultant for Lilly and Pfizer.