News Author: Deborah Brauser
CME Author: Laurie Barclay, MD
August 24, 2009 — A joint report from the American Psychiatric Association (APA) and the American College of Obstetricians and Gynecologists (ACOG) aims to provide a new resource for clinicians who care for pregnant women who either have or are at risk of developing major depressive disorder.
The report by Kimberly A. Yonkers, MD, from the Department of Psychiatry, Department of Obstetrics and Gynecology, and Department Reproductive Sciences, Yale School of Medicine, in New Haven, Connecticut, and colleagues, aims to help physicians and patients weigh the risks and benefits of various treatment options.
The report includes an extensive review of existing research and a list of treatment recommendations.
"We wanted to provide a comprehensive story of where the literature stands at this point so that one single study does not trump all the work that’s been done, and so clinicians have a full context," said Dr. Yonkers in an interview with Medscape Psychiatry.
"In terms of birth outcomes, the literature suggests that it’s likely that both depression as well as antidepressant treatment confer risks and may be associated with adverse birth outcomes. However, the data looking at both of these together are insufficient at this point," Dr. Yonkers added.
The report will be published in both the September/October issue of General Hospital Psychiatry and the September issue of Obstetrics & Gynecology.
In addition, the authors write that available research has not yet adequately controlled for other factors that may influence birth outcomes, including maternal illness or problematic health behaviors. The use of multiple medications during pregnancy also makes it difficult to assess the effect of a single compound, such as an antidepressant, on maternal and fetal outcomes.
According to the report, between 14% and 23% of pregnant women experience depressive symptoms, and approximately 13% of women in 2003 took an antidepressant at some time during pregnancy. "Thus, clinicians and patients need up-to-date information to assist with decisions about depression treatment during pregnancy," the authors write.
For the report, the authors sought "to address the maternal and neonatal risks of both depression and antidepressant exposure and develop algorithms for periconceptional and antenatal management." Representatives from the APA and ACOG and a consulting developmental pediatrician reviewed articles from Medline searches and bibliographies.
At the end of the review, the investigators found that although both depressive symptoms and antidepressant exposure are associated with fetal growth changes and shorter gestation periods, the majority of the studies that evaluated antidepressant risks were unable to control for the possible effects of a depressive disorder.
The researchers also found that:
- Neonates born to mothers with a depressive disorder have an increased risk for irritability, less activity and attentiveness, and fewer facial expressions compared with those born to mothers without depression.
- Several studies report fetal malformations in association with first-trimester antidepressant exposure, but there is no specific pattern of defects for individual medications or class of agents.
- The association between paroxetine and cardiac defects is more often found in studies that included all malformations, rather than clinically significant malformations.
- Late gestational use of selective serotonin reuptake inhibitor antidepressants is associated with transitory neonatal signs and an increased risk for persistent pulmonary hypertension in the newborn.
- Most of the studies did not show an association between tricyclic antidepressant use in pregnancy and structural malformations, but tricyclic antidepressants are associated with increased perinatal complications such as jitteriness, irritability, and convulsions in neonates.
The report also recommends several treatment algorithms. These common scenarios include the following.
Women Thinking About Getting Pregnant
- Tapering and discontinuing medication for those with mild or no depressive symptoms for 6 months or longer.
- This discontinuation may not be appropriate for women with a history of severe or recurrent depression (or who have psychosis, bipolar disorder, other psychiatric illness requiring medication, or a history of suicide attempts).
Pregnant Women Currently on Medication for Depression
- After a consultation between their psychiatrist and obstetrician/gynecologist (to discuss risks), psychiatrically stable women who prefer to stay on medication may be able to do so.
- For those who want to discontinue medication and are not experiencing symptoms, tapering and discontinuation may be attempted. However, women with a history of recurrent depression are at a high risk for relapse.
- Those with recurrent depression or symptoms despite their medication may benefit from psychotherapy to replace or augment medication.
- Women with severe depression should remain on medication. If a patient refuses, alternative treatment and monitoring should be in place, preferably before discontinuation.
Pregnant Women Not Currently on Medication for Depression
- For those who want to avoid antidepressant medication, psychotherapy may be beneficial.
- For those who prefer taking medication, risks and benefits of treatment choices should be evaluated and discussed.
In addition, regardless of circumstances, any pregnant woman with suicidal or psychotic symptoms should seek an immediate consultation with a psychiatrist for treatment.
"In the past, reproductive health practitioners have felt ill equipped to treat these patients because of the lack of available guidance concerning the management of depressed women during pregnancy. Many people — physicians and women alike — will be glad to know that their choices go beyond medication or nothing," ACOG President Gerald F. Joseph, Jr, MD, said in a statement.
Limitations of this report are that only a minority of the studies reviewed included information on maternal psychiatric illness. Studies with detailed information regarding diagnoses and antidepressant use were usually smaller and had limited power to find important associations.
In addition, confounding factors that influence birth outcomes, such as poor prenatal care and drug, alcohol, and nicotine use, were variably controlled.
"This is a report intended to reach out to psychiatrists as well as obstetrician-gynecologists," said Dr. Yonkers. "We developed algorithms which I think reflect the fact that there are multiple issues to consider and [that] there should be no knee-jerk response in managing a woman who is depressed and pregnant or contemplating pregnancy. Psychiatric history and a woman’s preference are among the important features that should be taken into consideration."
She added that collaboration between groups such as the APA and ACOG would be helpful for other disorders as well. "There are many psychiatric illnesses that are at their peak during the reproductive years, so I think there are a number of areas where the combined input would be extremely helpful."
The study investigators have disclosed several financial relationships, a complete list of which is available in the original article.
Gen Hosp Psychiatry. 2009;31:403–413.
Obstet Gynecol. 2009;114:703–713.