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

Transcranial Magnetic Stimulation

Transcranial magnetic stimulation (TMS) is a novel device technology which noninvasively delivers focused magnetic pulses to the surface of the brain.[74,75] When the magnetic pulses reach the cortex the counter-current physical principle of electromagnetism causes local current flow and thus local neuronal depolarization. For depression, TMS is given over the left dorsolateral prefrontal cortex (DLPFC) at a high frequency or over the right DLPFC at low frequency. TMS has been researched as a putative treatment for MDD for just over a decade. In all there have now been over 35 controlled clinical trials. Recent meta-analyses of the database of TMS studies show clear efficacy with an effect size of 0.75 (moderate-to-large) and a very favorable tolerability profile (a discontinuation rate of approximately 5% owing to adverse events in short-term clinical trials).[76] In 2008, the US FDA approved TMS as a new treatment for MDD in patients who fail one adequate antidepressant medication trial. The most common side effect is headache, although rarely seizure, facial numbness and hearing loss have been reported.[77] As no sedation or analgesia is required, TMS offers a potent CNS active treatment without exposing the fetus to the effects of drugs that cross the placenta.

Based on these findings, investigators have begun to look at TMS for depression during pregnancy. To date, there are only six cases in the literature regarding the use of TMS for depression during pregnancy.[78–80] In all cases, maternal depression improved. The first case study regarding the use of TMS in a depressed pregnant woman was published in 1999. Treatment began at week 22 of pregnancy (second trimester).[78] The patient received 14 days of treatment over the course of 3 weeks. Her depression remitted and she delivered a healthy 7.5 lb term infant. There was no change in the patient's blood pressure, oxygen saturation or heart rate during any of the TMS procedures. The next two patients were reported in 2008.[79] One patient received 15 sessions of left DLPFC TMS. The treatments were started at 16 weeks of pregnancy. The second patient started right DLPFC TMS at 31 weeks of pregnancy for 15 sessions. Both patients had greater than 50% reduction in depression scores. One infant was born at 36 weeks but the mother was also taking venlafaxine. Both infants were reported to be healthy but no specific information regarding how this was assessed is given. Most recently, in 2009, an additional three cases were reported.[80] No details concerning the frequency, duration, number of pulses or sessions were given. While details were not provided, the authors made a general statement that the infants were born in 'good health'.

These cases suggest that TMS may eventually be a viable option for depression during pregnancy both as a primary treatment and as an adjunctive treatment. However, these are case reports and to date there has been no systematic study of this hypothesis. TMS, similar to ECT, requires collaboration with a trained behavioral health specialist trained in administering TMS. As with ECT, women are required to attend to a treating facility between three- and five-times per week. However, as TMS does not require any pharmacologic agents and patients can resume daily activities immediately after a treatment session, TMS may provide some practical advantages to patients, with potential efficacy in those who have failed either antidepressant medication or psychotherapy. While TMS cannot be recommended at this time, practitioners are advised to be aware of this treatment as it is likely to be a future option for pregnant women with depression.

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