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A Guide to Managing Depression in Pregnancy : ACOG and APA collaborate on recommendations for treatment depending on disease severity.


 

Women taking antidepressants who are thinking about getting pregnant might consider tapering or discontinuing drug therapy if they have experienced only mild or no symptoms for at least 6 months, depending on their psychiatric history, according to a new report on the treatment of depression during pregnancy.

The report, issued jointly by the American Psychiatric Association and the American College of Obstetricians and Gynecologists, also said medication discontinuation might not be appropriate for women with a history of severe recurrent depression or those who have psychosis, bipolar disorder, other psychiatric illness requiring medication, or a history of suicide attempts.

The report was published in the September issue of Obstetrics and Gynecology, and produced by an APA/ACOG work group convened to evaluate and summarize information about the risks associated with depression and antidepressant therapy during pregnancy. Representatives from both professional associations, along with a consulting developmental pediatrician, conducted a critical review of published literature on fetal and neonatal outcomes associated with depression and antidepressant treatment during childbearing.

The authors concluded that the symptoms of depression and exposure to antidepressant therapy might be linked to certain fetal growth and development changes, “but the available research has not yet adequately controlled for other factors that may influence birth outcomes, including maternal illness or problematic health behaviors that can adversely affect pregnancy,” wrote lead author Dr. Kimberly A. Yonkers of Yale University, New Haven, Conn., and her colleagues (Obstet. Gynecol. 2009;114:703–13). The report is being published concurrently in the September/October issue of General Hospital Psychiatry (doi:10.1016/j.genhosppsych.2009.04.003

For preconceptional patients receiving pharmacologic treatment for depression, a determination of the severity of symptoms should guide management recommendations, the authors wrote. Patients with suicidal or acute psychotic symptoms should be referred to a psychiatrist for aggressive treatment and counseled to wait a period of time after achieving euthymia before conceiving.

Similarly, patients with moderate to severe symptoms should continue and optimize antidepressant therapy and wait for a period of time before conceiving.

“While it is difficult to specify an exact or optimal length of time for all patients, guidelines such as those from the [Agency for Healthcare Research and Quality] suggest antidepressant treatment for a first, acute episode of depression should endure at least 6–12 months,” they wrote.

For women with mild or no symptoms for at least 6 months who are candidates for medication discontinuation, the decision to initiate a treatment hiatus should be made in consultation with her psychiatrist, and the subsequent taper should be slow—such as a 25% reduction in dose every 1–2 weeks with close monitoring for relapse, the authors said.

The obstetrical care of women with a history of severe, recurrent mood disorders who continue drug treatment should also be coordinated with the psychiatric provider to monitor for illness relapse, they wrote, noting also that some women may benefit from individual or group psychotherapy, alone or in combination with medication.

Women with untreated depression that is diagnosed during pregnancy and those with depression who have discontinued their medication should similarly be evaluated for symptom severity and, if necessary, referred for psychiatric consultation, according to the report.

For patients with severe depressive, suicidal, or psychotic symptoms, the use of antiepileptic agents, newer antipsychotic drugs, and antidepressants should be avoided in the first trimester, if possible, because of the teratogenic potential of the antiepileptics and relative lack of reproductive safety information for the newer antipsychotics and antidepressants, the authors stated.

Those women who are not “gravely disabled or at high risk of relapse” may benefit from psychotherapy, and those with bipolar affective disorder should be managed by a psychiatrist because of the risk that antidepressant monotherapy could trigger mania and psychosis, they wrote.

In all women who begin antidepressant treatment during pregnancy, the treatment choice should be guided by the drugs' safety profile and the stage of gestation, as well as the patient's symptoms, history, and preferences, the authors stressed.

For women who are taking antidepressant medication when they become pregnant, “if the patient is willing to consider discontinuation of medication and she is not currently having symptoms, then, depending upon the individual's psychiatric history, a trial of medication taper may be appropriate,” the authors wrote. They noted, however, that “women with a history of severe, recurrent depression, even if currently asymptomatic or minimally symptomatic, are at a high risk of relapse if medication is discontinued.” For those women who prefer to continue medication, “discuss risk/benefit issues and document this discussion and the patient's choice, in her medical record,” they advised.

If a woman being treated for severe depression refuses to continue medication, alternative treatment, such as psychotherapy, and close monitoring are advised. Similarly, women with depressive symptoms or recurrent depression despite medication, might benefit from the addition of psychotherapy, the authors wrote.

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