Managing Unipolar Depression In Pregnancy

Julia Raudzus; Shaila Misri

Disclosures

Curr Opin Psychiatry. 2009;22(1):13-18. 

In This Article

Abstract and Introduction

Abstract

Purpose of Review: The management of depression in pregnancy is complex, as it is based on balancing the risks with the benefits of treatment versus no treatment for both the mother and the fetus. The current literature in the field of reproductive psychiatry is difficult to navigate and at times contradictory. This article aims to review both nonpharmacological and pharmacological modalities in the treatment of perinatal depression. A literature review using PubMed and MEDLINE databases was used to collect literature from the past 2 years; however, given the relatively small amount of research in reproductive psychiatry, several salient articles from the past 5 years have also been included in this review.
Recent Findings: Recent US Food and Drug Administration and Health Canada warnings regarding poor neonatal adaptation and adverse perinatal outcomes associated with antidepressant use in pregnancy have changed patterns of practice for prescribing physicians. Many physicians are now left with a sense of indecisiveness regarding the safety of treating their depressed, pregnant patients. Similarly, these warnings have changed patients' attitudes and their willingness to consider pharmacological treatment for depression. Although these warnings demand attention and careful consideration, research has also shown that exposure to mental illness in pregnancy has deleterious short-term and long-term effects for the exposed mother and fetus.
Summary: The field of reproductive psychiatry is rapidly evolving. Clinicians need to keep abreast of changes in the management of depression during pregnancy. Ongoing research in this field is important so that the most up-to-date recommendations may be provided to pregnant women.

Introduction

Pregnancy has typically been viewed as a time of emotional well being, one that the general public and many medical professionals feel confers emotional protection.[1••] Consequently, depression during pregnancy is often overlooked and underdiagnosed. Although there has long been a focus on depression in the postpartum period, with a wealth of existing research and numerous celebrity advocates contributing to public awareness, antenatal depression has been relegated to somewhat of an unnoticed disease, often lacking appropriate consideration and attention.

This is particularly a concern given that depression in pregnancy is common. One large meta-analysis has reported the range of antenatal depression to be between 6.5 and 12.9%.[2] Similarly, a systematic review of the literature in 2004 estimated the prevalence of depression as 7.4% (2.2-12.6%), 12.8% (10.7-14.8%) and 12.0% (7.4-16.7%) for each trimester of pregnancy, respectively.[3] Moreover, women with a history of major depression are at high risk for relapse during pregnancy, even more so if they discontinue antidepressant medications during this vulnerable period.[4]

In addition, research from the past two decades has suggested a possible, though still controversial,[5•] link between perinatal maternal psychological distress and adverse neonatal outcomes. A review conducted by Alder et al. [6•] concluded that the presence of depression during pregnancy was an independent risk factor for subsequent adverse obstetric, fetal and neonatal outcomes. A growing body of research has demonstrated that some of the risks of untreated depression in pregnancy may include poor prenatal care, medical and obstetrical complications, self-medication, substance abuse, impaired bonding, suicide and an increased risk of relapse of depression in the postpartum period.[7•,8•,9]

It is of concern then, despite the identification of significant rates of depressive symptoms in pregnancy, that few pregnant women receive treatment.[10] Women with serious mental illness during pregnancy continue to go undiagnosed and untreated.

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