Unipolar Depression During Pregnancy: Nonpharmacologic Treatment Options

Christopher Tjoa; Emmanuelle Pare; Deborah R Kim

Disclosures

Women's Health. 2010;6(4):565-576. 

In This Article

Treatment Issues

With respect to the treatment of MDEs during pregnancy, practitioners should know that the current vanguard of evidence exists as consensus practice guidelines, produced by combined task forces of the American Psychiatric Association (APA) and the American College of Obstetricians and Gynecologists (ACOG).[28,29] Available guidelines inform both primary care providers and mental health providers. Providers are instructed to weigh several factors in choosing an appropriate therapy, including whether the individual was taking medication at the time of assessment, the severity of symptoms, and past response to psychotherapy. Primary providers are urged to collaborate with mental health providers when patients demonstrate severe symptoms – suicidal ideation, psychosis, mania or bipolar depression, psychiatric comorbidity or a history of poor response to psychotherapy. Providers should also emphasize healthy lifestyle choices, prenatal education, and screening and treatment of comorbid addictions. Psychotherapy, antidepressants and electroconvulsive therapy are all addressed in the guidelines as potential treatment options.

Amongst all treatment options, pharmacologic antidepressant treatments have been the subject of closest scrutiny. While a thorough review of the numerous issues raised by the pharmacological treatment of depression in pregnancy is beyond the scope of this article, we refer to several sources that have addressed this issue.[16,28–33] Briefly, the majority of research has focused on the risks of antidepressant medication to the developing fetus, and available data suggest serotonin-reuptake inhibitors (SSRIs) and tricyclic antidepressants do not increase rates of major congenital malformations,[29,34,35] although concerns have arisen surrounding reports of low but significant rates of SSRI-attributed cardiac septal defects,[36] persistent pulmonary hypertension of the newborn,[30,32] preterm birth[16,33] and neonatal withdrawal.[31] Conclusive data regarding the fetal risks of pharmacologic treatments are currently unavailable, and available reports have yet to show consistency in these rates. The use of antidepressants during pregnancy requires an evaluation of the risks and benefits for each patient.[15] While fetal safety concerns have drawn the most scientific attention, the efficacy of antidepressant medications during pregnancy remains an understudied issue, with no available randomized placebo-controlled trials. Pregnant women with depression represent a challenging and important study population for multiple reasons, including ethical issues[37,38] and variable pharmacokinetics of the pregnant state.[39,40]

Clinically, when pregnant women are surveyed regarding their treatment preferences for depression, medications are reported to be their least acceptable option.[41–43] Women who are given antidepressants during pregnancy are often treated at inadequate doses, exposing the fetus to a harm profile without any clear therapeutic effect. In addition, it must be acknowledged that the majority of women on antidepressants discontinue use at conception,[44] potentially leading to fetal harm via documented risks of undertreated maternal depression.

There are data supporting psychotherapy as a robust treatment for depression during pregnancy. Two randomized controlled studies have shown interpersonal therapy to be efficacious for mild[45] and moderate[46] depression during pregnancy. There are no randomized or controlled trials of psychodynamic psychotherapy or psychoanalysis to support their use in this special population, owing partly to the difficulty in designing studies to assess these interventions. Despite widespread use in nonpregnant populations, cognitive behavioral therapy has not been studied in pregnancy, although studies are currently underway.[47] Current guidelines suggest psychotherapy be considered as a primary treatment option for depression during pregnancy,[28] and availability of treatment, a low side-effect burden and purported efficacy make psychotherapy a viable treatment option in this population. However, access to skilled practitioners may be an issue in some geographical areas and patients presenting with severe depressive symptoms may not be appropriate for psychotherapy without psychopharmacologic intervention.

An option for women with severe MDD is electroconvulsive therapy (ECT). While there have been no randomized controlled trials clarifying its efficacy or safety in MDD during pregnancy, a recent extensive case review by Anderson et al. provides some evidence in this regard.[48] Anderson et al. looked at 57 articles from 1941–2007, which reported on 339 individuals who received ECT during pregnancy. Of the subpopulation that was treated for MDD without psychosis, 84% were found to experience 'at least a partial response'. There were 11 reported fetal deaths, with one directly attributed to ECT, whereby a woman experienced ECT-induced status epilepticus. The most common adverse fetal effect was a transient bradyarrythmia. In addition to confusion, headache, amnesia and muscle soreness, 3.5% of women experienced uterine contractions or preterm labor. Similar to its role in the treatment of MDD in the general population, ECT is best considered a second-line treatment to be judiciously used in cases requiring urgent symptomatic relief, including women who are experiencing co-occurring psychosis, catatonia or disabling levels of suicidality.

Complementary and herbal medicines represent pharmacologic treatment alternatives for depression and are thought to have fewer adverse effects, although there is little scientific affirmation of this claim. Freeman recently reviewed complementary and alternative medicine strategies for perinatal (all times during and after pregnancy) depression, finding omega-3 fatty acid supplementation to be the most studied approach.[49] Her review concluded that exercise, omega-3 fatty acids and folic acid are promising treatment options in antepartum depression given their probable safety and potential efficacy, warranting more conclusive studies. While none of the studies reviewed studied severe depression, it is unlikely that monotherapy with complementary and herbal medicines would be adequate treatment of moderate to severe MDEs.

Nonpharmacologic treatment options for depressed pregnant women comprise an important and active area of research. Below, we discuss current data regarding these options.

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