SAN FRANCISCO — Consider not only the risks of antidepressant drugs but also the risks of not treating depression during pregnancy, Dr. Andrea J. Singer recommended.
Approximately 1 in 10 women become depressed at some point during pregnancy. In addition to nonpharmacologic therapies such as increased social support, cognitive-behavioral therapy, or counseling as first-line treatments, many depressed women need supplemental antidepressant medication, she said at the Perspectives in Women's Health conference sponsored by OB.GYN. NEWS.
“How we treat depends on the severity of depression. There are clear data that a significantly depressed mother is at more risk than a mother on antidepressant medication,” Dr. Singer, director of women's primary care at Georgetown University Medical Center, Washington, said at the meeting.
Because the effectiveness of antidepressant medications generally is comparable between classes and within classes of drugs, the choice of pharmacotherapy—and which medication—rests on questions of safety and tolerability for both the mother and fetus, patient preference, cost, and the quantity and quality of data available on the drug.
If depression is not adequately treated, the woman will have a higher risk for suicide, poor maternal and fetal nutrition, adverse neonatal outcomes, continued depression into the postpartum period, and impaired mother-child bonding, said Dr. Singer.
Depression during pregnancy is associated with an increased likelihood of using drugs, alcohol, or nicotine and a decreased likelihood of getting early prenatal care.
Depressed pregnant women often don't report depression but more often complain of physical health problems, compared with nondepressed pregnant women, she added.
The incidence of premature births is higher in depressed than in nondepressed women. Compared with term deliveries, children born prematurely tend to perform less well in school, are less likely to graduate from high school, and have higher rates of neurosensory impairments, bipolar disorder, and subnormal height.
Antidepressants probably are the best-studied class of drugs used during pregnancy, though the amount of data from controlled clinical trials still is small, said Dr. Singer. She is on the speakers' bureau of Pfizer, which makes the SSRI sertraline.
Two studies in the past decade encompassing a total of 1,089 women found no causal relationship between use of tricyclic and noncyclic antidepressants and adverse pregnancy outcomes, Dr. Singer said.
In general, no increase in teratogenic risk has been found with use of the SSRIs fluvoxamine or sertraline, which are the antidepressants most commonly prescribed for pregnant women.
One recent study suggests that paroxetine use during the first trimester might be associated with an increased risk of cardiovascular birth defects, particularly ventricular septal defects, she said.
In addition, there have been several reports of possible withdrawal symptoms in babies who were exposed to SSRIs during or at the end of the third trimester. The reports describe neonatal jitteriness, irritability, or respiratory difficulties.
Physicians may want to consider temporarily halting maternal SSRI therapy near the end of the third trimester in some patients who can tolerate an interruption in therapy and restarting the medication in the postpartum period, Dr. Singer suggested. Watch neonates born to women who took SSRIs late in pregnancy for potential withdrawal signs, she added.
The women at greatest risk for developing depression during pregnancy are those with a history of depression before pregnancy. “That's a red flag to follow the patient closely during pregnancy,” she said.
Other risk factors for depression during pregnancy include a history of premenstrual dysphoric disorder, younger maternal age, living alone or with limited social support, ambivalence about the pregnancy, conflict with her spouse or significant other, and having multiple other children.