Women, Wellness, & Wisdom

Perinatal Depression – The Antidepressant Treatment Dilemma

Perinatal Depression – The Antidepressant Treatment Dilemma

Perinatal Depression – The Antidepressant Treatment Dilemma

Vandna Jerath, MD


Depression disrupts daily life and affects thoughts, feelings, behavior, and relationships that have a significant impact on mental, emotional, social, professional, and physical well-being.  Women are twice as likely as men to have depression.  Clinical depression is common among reproductive age women 25-45 and the leading cause of disability in women in the U.S.  This can account for $30-50 billion in lost productivity or medical costs. 


Perinatal depression refers to depression that occurs during pregnancy and postpartum up to one year after delivery.  14%-23% of women experience depression during pregnancy and 5%-25% of women will have postpartum depression.  It is essential that perinatal depression be treated as it can lead to sporadic prenatal care, inadequate nutrition, poor fetal growth, preterm delivery, preeclampsia, low birth weight, self-medication with tobacco, alcohol, or drugs, increased risk of postpartum depression, inability to care for self or child, lack of mother-infant bonding,  and in extreme cases may lead to suicide or infanticide.  Studies have shown that untreated maternal depression negatively affects an infant’s cognitive, neurologic, and motor skill development and can also impact older children’s mental health and behavior.


Symptoms of depression include:



  • Sadness

  • Trouble sleeping – Insomnia or increased sleeping

  • Feelings of guilt, worthlessness, or hopelessness

  • Lack of motivation or interest

  • Decreased energy

  • Changes in appetite with weight loss or gain

  • Difficulty concentrating

  • Psychomotor retardation or agitation

  • Thoughts of death or suicide

  • Anxiety, worry, and fear

  • Physical  manifestations of body aches, digestive problems, fatigue, or  sexual dysfunction

Treatment options for depression in pregnancy include:



  • Therapy

    • Psychotherapy

    • Cognitive Behavioral Therapy

    • Support Groups

    • Family, friends, church, community

    • Antidepressants

      • Tricyclic Antidepressant (TCA)

        • Elavil (amitriptyline)

        • Pamelor (nortriptyline)

        • Tofranil (imipramine)

        • Sinequan (doxepin)

      • Selective Serotonin Reuptake Inhibitor (SSRI)

        • Prozac (fluoxetine)

        • Zoloft (sertraline)

        • Paxil (paroxetine)

        • Celexa (citalopram)

        • Lexapro (escitalopram)

      • Monamine Oxidase Inhibitor (MAO)

        • Nardil (phenelazine)

        • Parnate (tranylcypromine)

      • Alternatives

        • Wellbutrin (bupropion) – also good for smoking cessation

        • Effexor (venlafaxine) – SNRI

        • Cymbalta (Duloxetine) – SNRI

    • Alternative Therapy (still being studied/investigated)

      • Exercise – yoga

      • Massage

      • Light therapy

      • Acupuncture

      • Omega 3

      • Calcium

      • Herbs

        • St John’s Wart (very little known about the effect on the fetus)

      • Electroconvulsive Therapy (ECT) – safe in pregnancy

      • Transcranial magnetic stimulation

As many as 1 in 4 pregnant women may suffer from depression, and about 1 in 8 receives treatment with antidepressants.  If a pregnant woman was previously on antidepressants then it is not advisable to stop abruptly as she may experience nausea, vomiting, fatigue, anxiety, and irritability.  Additionally, a 2006 study in Journal of American Medical Association (JAMA) found that  68% of women who discontinued their antidepressants in pregnancy experienced a relapse of their depression. 


Many antidepressants and drugs have been used for many years without any obvious signs of serious risk to the baby.  There are some potential concerns, side effects, and risks associated with the anti-depressant medications.  However, studies have had small sample sizes, conflicting data, and lack of consistency with findings. 


MAOIs are not typically recommended as they can limit fetal growth and aggravate maternal high blood pressure.  There appears to be a small potential risk of fetal malformation with antidepressants, but not higher than the average overall risk of malformations in the general pregnancy population which is 1-3%.  Previously, there were concerns for limb defects with TCAs, but these results have not been reproduced in future studies.  TCAs are considered safe, but blood levels may need to be monitored during treatment.  SSRIs may be associated with low birth weight, preterm birth, and miscarriage.  Of all the SSRIs, Paxil is a category D and not recommended in pregnancy due to initial studies showing possible cardiac defects of the fetus when taken in the first trimester of pregnancy.  15-30% of babies whose mothers took SSRIs late in pregnancy may experience withdrawal  symptoms with irritability, jittery behavior, weak crying, hypoglycemia, seizures, temperature instability, and tachypnea.  These symptoms typically resolve within two weeks.  The remaining SSRIs are considered safe, but there have been some inconsistent findings of cardiac septal defects (“holes in the heart”) which typically occur in less than 1% of babies and resolve spontaneously without treatment, omphaloceles,  and neural tube defects.  There have been no studies showing any neurobehavioral , IQ, or language problems.   There has inconsistently been an increased relative risk of persistent pulmonary hypertension of the newborn (PPHN).  


PPHN is a condition which causes an elevation in the pressure of the pulmonary artery causing a patent ductus arteriosis and right to left shunting of blood through the heart which results in hypoxia  (lack of oxygen) to the baby and results in respiratory distress.  Most cases are treatable and 10% of cases can be fatal.   Risk factors for PPHN can include meconium aspiration, maternal obesity, smoking, diabetes, or maternal use of non-steroidal anti-inflammatory drugs (NSAIDs).  It can normally occur in 1-2/1000 infants.  Based upon 6 studies from the past 15 years, for those pregnant women taking SSRI medication there can be no association to a 6-fold increased risk of PPHN.  Most recently a study published in British Medical Journal (BMJ) on January 12, 2012 reveals that SSRI treatment in pregnancy may double the risk of PPHN as their findings from 1.6 million infants revealed an incidence of 3/1000 rather than the normal 1.2/1000.  Although, the risk may be two-fold in this study, it is still clearly extremely low.


The FDA recently made a safety announcement regarding SSRI and PPHN on December 14, 2011:


FDA has reviewed the additional new study results and has concluded that, given


the conflicting results from different studies, it is premature to reach any conclusion


about a possible link between SSRI use in pregnancy and PPHN . . . At this time, FDA advises health care professionals not to alter their current clinical practice of treating depression


during pregnancy.


 


The FDA had not evaluated the recent BMJ study which was published a few weeks later.  However, it is unlikely the findings would have changed their recommendation as it was another conflicting result.


 


This poses the question as to whether it is worse to have depression during pregnancy or take medication for it?  As outlined at the beginning of this discussion, untreated depression in pregnancy can lead to multiple maternal, obstetrical, and neonatal problems.  As for the antidepressant options, no drug is 100% safe, but most are considered  safe and effective for treatment and may be necessary depending upon the severity of maternal depression.  Additionally, in some cases the duration of treatment can be targeted to not start until after embryogenesis is complete at 8-10 weeks and discontinued in the third trimester before delivery to reduce risks of withdrawal and PPHN.  However, if there is severe maternal depression this would not be advisable as it increases the risk of postpartum depression.


Postpartum blues encompasses mood symptoms such as crying, anxiety, trouble sleeping, feeling sad or doubt, and being overwhelmed that may occur immediately postpartum, but subside within two weeks without treatment.  70-80% of women will have some “baby blues”.  Postpartum depression is depression and anxiety symptoms that occur anytime postpartum up to 1 year after delivery and interfere with daily functioning.  The condition may occur from an imbalance or adjustment of hormones, body changes, lack of sleep, feeling overwhelmed as a mother, lack of support or socialization, loss of freedom/identity, genetic predisposition, and breastfeeding problems.  The same treatment options can be used during the postpartum period and most antidepressants are considered safe during breastfeeding.  Antidepressant exposure through the breast milk is significantly less than transplacental exposure and is not associated with significant risks to full-term and healthy infants.


The risks and benefits of taking an antidepressant during pregnancy must be weighed carefully.  Ultimately, it is best to treat each patient individually, case by case to determine the best course of action and treatment.  Whenever possible, multidisciplinary management involving the obstetrician, mental health clinician, primary care provider, and pediatrician is helpful to facilitate and coordinate care.  It is essential that we screen and treat perinatal depression and stabilize maternal mental health for the overall well-being of mom and baby.  

optimawomenshealthcare.com
 

Photo Credit: Stock Photo

2 thoughts on “Perinatal Depression – The Antidepressant Treatment Dilemma

  1. Tamara G. Suttle

    Hi, Vandna! Happy to find you here and on Pinterest, too!

    Just wanted to drop you a note and say that I particularly appreciate you addressing the mental health of both mother and child . . . and also including mental health professionals as part of a successful treatment plan.

  2. Optima Womens Healthcare Blog

    Tamara- Thanks for your comments.  Mental health professionals are indeed essential to adequate treatment of the mother with perinatal depression. 

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