Antidepressants 'Last Resort' Choice Among Pregnant Women

Deborah Brauser

December 13, 2013

The majority of pregnant women with depression cite a preference for nonpharmaceutical treatment interventions, preliminary research suggests.

Results from the study show that 62% of the pregnant women said they would rather receive some form of psychotherapy as first-line treatment rather than antidepressants.

In addition, many of the participants reported that they would only consider using antidepressants during pregnancy as a "last resort."

Reasons cited ranged from fear of adverse developmental events in the baby to developing dependence on medications.

"Findings from this study point to a need for greater decisional support for depressed perinatal women, as well as enhanced support and training for clinicians who provide care for these patients," investigators, led by Cynthia L. Battle, PhD, from the Department of Psychiatry and Human Behavior at Brown University and Butler Hospital in Providence, Rhode Island, write.

They add that providing better education as part of the decision-making process and discussing known risks and potential benefits can increase patients' comfort levels with various treatment options, including antidepressants.

However, they also note that it is important to raise awareness of effective nondrug treatments for depression during pregnancy ― and cite alternative interventions such as yoga, exercise, and light therapy as possible options worth further research.

The study was published in the November issue of Journal of Psychiatric Practice.

Depression in Pregnancy Common

According to the investigators, nearly 13% of all pregnant women experience at least 1 episode of major depression. This rate is even higher for those from low-income and minority backgrounds.

Yet, the majority of these women receive no mental health treatment for a variety of reasons, including a lack of insurance coverage and logistical difficulties.

Although previous studies have also noted a general reluctance by these women to take medications during pregnancy and immediately following birth, the researchers note that they wanted to explore specific concerns, preferences, and motivations influencing this phenomenon.

The investigators conducted in-depth telephone interviews with a cohort of 61 pregnant women between the ages of 18 and 40 years (mean age, 28.7 years; 71% white, 20% Hispanic) who were at 32 weeks' gestation. All were part of a larger study on fetal and neonatal outcomes following prenatal antidepressant use.

On the basis of several measures, including the Hamilton Rating Scale for Depression (HAM-D; mean score, 11.4) and the Beck Depression Inventory (BDI; mean score, 15.8), 51% of the women were diagnosed with mild to moderate depression at study outset.

To measure treatment uncertainty, the Decisional Conflict Scale (DCS) was administered via phone interviews to depressed patients. In addition, all women, regardless of depression status, were asked about hypothetical treatment preferences.

Patient Opinion Matters

Results showed that 71% of depressed participants received some form of depression treatment during their pregnancy. These included psychotherapy plus a selective serotonin reuptake inhibitor (SSRI) (n = 11), an SSRI only (n = 6), or psychotherapy only (n = 5).

One third of the depressed women reported having a high degree of uncertainty and confusion about their treatment.

Those with higher uncertainty levels on the DCS were found be less likely to follow through with treatment adherence. They also had significantly higher depression scores on the BDI (P < .05) and a trend toward higher scores on the HAM-D.

Interestingly, some women voiced positive comments about their treatment, regardless of whether it was with psychotherapy or with antidepressants.

"Others noted that obtaining some form of treatment during pregnancy would be a critical step in preventing a more serious episode of depression later in pregnancy or during the postpartum period," write the investigators.

Still, most of the positive comments were related to psychotherapy, and most of the negative comments were related to antidepressant medications.

Of all the participants, 62% cited individual, family, or group therapy as their preference for first-line depression treatment. Alternative treatments, including exercise, walking, omega-3 fatty acids, and yoga, were the next most endorsed strategy, cited by 15% of the women. Antidepressants were endorsed by only 8%.

The overall results highlight the importance of increasing patient involvement in the decision-making process.

"Placing greater emphasis on understanding and responding to the unique needs and preferences of perinatal patients is consistent with our healthcare system's growing emphasis on patient- centered care," they write.

A Clinical Challenge

"I think this study is a helpful addition to the literature because treatment preferences and patient experiences are not typically reported," Katrina C. Johnson, PhD, assistant professor of psychiatry and associated faculty in the Department of Psychology at Emory University in Atlanta, Georgia, told Medscape Medical News.

"And I thought they did a good job acknowledging the limitations, including the lack of racial diversity and the small sample size. Overall, I thought it made a nice contribution," said Dr. Johnson, who was not involved in the research.

She added that the take-home message is that treatment decision-making should be a collaborative process between a patient and a healthcare provider.

"From the beginning, a certain level of rapport and openness should be established so that patients feel comfortable asking questions, reporting symptoms, and talking through options," said Dr. Johnson.

Results from a small prospective study she published last year in the Archives of General Psychiatry showed that infants who had been exposed prenatally to antipsychotics had lower neuromotor performance scores compared with infants who had not been exposed to any psychotropic medication.

However, she noted at the time that mental illness itself can be harmful for a baby's development, so mothers should not just stop taking their medication.

"Talking with their physician and really weighing risks and benefits is important," she said. "Disentangling medication effects from maternal [mental] illness effects, which also contributed, remains a clinical challenge."

Dr. Johnson also noted that the current study's finding that 62% of the women preferred psychotherapy suggests the need for more research into the efficacy of this type of intervention for both perinatal depression and anxiety.

"For the pregnant woman, there's currently not a great option, and there isn't an easy answer. And I think it's important that we help patients to understand that," she said.

"It's also important to then help them understand individual factors that can help determine which treatment might be appropriate for their particular situation. There's some great research showing that psychotherapy is effective, it just often takes longer, and the effects are slower. So that's something to evaluate with your patient."

The study was funded by grants and awards from the National Institute of Mental Health. The study authors and Dr. Johnson report no relevant financial relationships.

J Psychiatr Pract. 2013;19:443-453. Abstract


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