Management of Depression During Pregnancy- The Controversy Continues

Balancing the wellbeing of the mother and developing fetus is a central challenge of obstetrics, and management of depression is one area where the balance between concerns is especially difficult to maintain. An interesting new study by Drs. Nakhai-Pour, Broy and Berard, published in the May issue of CMAJ adds insight and further controversy to the ongoing debate.

Major depressive disorder is prevalent among reproductive age women, and untreated, is associated with significant risks for the woman. The World Health Organization lists depression as the number one cause of disability for women. Pharmaceutical therapies are a common mainstay of treatment, and nearly 4% of pregnant women will use an antidepressant therapy during pregnancy.

A nicely designed prospective cohort study by Dr. Cohen, published in 2006 in JAMA, showed that discontinuation of pharmacotherapy among women during pregnancy (inclusion criteria included three months of stable mood prior to conception) was associated with a dramatically higher risk of relapse than maintenance of therapy.

It is generally recognized that the decision about use of antidepressants during pregnancy must be an individualized decision, with careful consideration of the risks for the woman of discontinuing the therapy and close monitoring and support. This new study, a nested case control study, is of interest in that it looks at the risk of spontaneous abortion among women using antidepressants.

Few previous studies have focused on miscarriage as a primary outcome, and limited data exists on risk of spontaneous abortion with type of antidepressant used. Dr Nakhai-Pour and colleagues found, is that use of pharmacotherapy, especially  paroxetine, venlafaxine or a combination of classes of antidepressants, during pregnancy was associated with an increased risk of spontaneous abortion (OR 1.68, 95%CI 1.38-2.06).

These results are of interest to our patients with depression and history of miscarriage, but the findings should be interpreted with caution, and further data is definitely needed before clinical practice recomendations should change. While the authors made every effort to adjust for potential confounders, a case control study has limitations inherent to its design, such as relying on medical records and billing data to document exposure to the drugs of interest. Given the prevalence of both depression, pharmacotherapy and miscarriage, a prospective cohort study would be an ideal way to follow women actively attempting conception and using antidepressants.

How do you counsel women in your practice who desire pregnancy but are currently using an antidepressant?

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