Challenges in treating depression during pregnancy :AJP: Jan:2013

24.01.2013

The idea that pregnancy is protective against depression no longer holds true. The rates of mood disorders in women are approximately equivalent in pregnant and non child-bearing women.Prevalence of major depression in pregnancy is in the range of   3 %–5%.Incidence is around 8% for major depression.Risk factors are similar to postpartum depression i.e. history of depression, poor social support, unintended pregnancy, lower socio- economic status, domestic violence, being single and  having anxiety/stressful life events.

Linda H. Chaudron reviews the challenges in treating depression during pregnancy in this article.

Impact on pregnancy: glucocorticoids (part of neurobiological changes in depression)  that cross the placenta could have direct effects. Hyperactivity of HPA can induce placental hypersecretion of corticotropin-releasing factor and this can increase myometrial contractility, leading to preterm delivery or pregnancy loss. Poor health behaviours associated with depression can also have deleterious effects on the foetus.

Impact on foetus: Depression is associated with preterm delivery and postpartum depression and developmental delays. Untreated depressive symptoms ( compared to SSRI treatment) are associated with lower total fetal body growth and head growth during pregnancy.

Treatment Vs no treatment: We have much less information on the impact of depression on mother/foetus/neonate as compared to treatment. One study found that only one third  of women who have major depression in pregnancy  receive antidepressants. However, use of antidepressants in pregnancy had increased more than twofold in a decade.Highest prevalence of antidepressant use is during the first trimester  and the rate decreases as pregnancy progress, possibly due to concerns about neonatal adaptation syndrome.

Effect of antidepressants (AD) on foetus: Relationship is complex to study and interpret ( where the participants really taking the medications?  Measure of alcohol/smoking/comorbid physical factors? ….all these factors need to be considered in interpreting the results of any associations). Studies suggest that AD can be associated with pregnancy loss , growth reduction , preterm birth, and malformations .Impact on neonates: neonatal adaption ,  motor development , persistent pulmonary hypertension, and behavioral effects.

Psychotherapy ,Bright light therapy and ECT are potentially effective treatments.

Authors provide  a general frame-work and strategies for consideration in treating depression.Individual’s history of depression and current risk assessment (of untreated depression as well as of interventions) is fundamental to this.Limitations of our knowledge need to be communicated to the person. Collaboration with obstetrician and pediatrician may also be crucial to ensure optimum care.

Summary of the article: 

Complex challenges in treating depression during pregnancy. Chaudron LH. Am J Psychiatry. 2013 Jan 1;170(1):12-20

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