Question:
Question
Is psychotherapy the first-line treatment for depression in a pregnant
woman, or are there antidepressants that are known to be safe during
pregnancy? Which antidepressants are safe to use for postpartum
depression during breastfeeding?
Answer:
This is a very difficult question. Women may consult with their
physicians about this issue when they have a new episode of depression
that arises during pregnancy, when they have an unexpected pregnancy
while being treated for depression, or when they are planning a
pregnancy while being treated for depression. There is increasing
evidence that psychotherapy is approximately equal in effectiveness to
pharmacotherapy for the treatment of acute, mild-to-moderate episodes of
depression, although it may not be effective as the sole treatment for
severe episodes or for maintenance therapy.
All antidepressants are rated as Category C for use in pregnancy because
definitive studies in humans do not exist. However, some studies
regarding the use of various antidepressants during pregnancy are
beginning to appear. Wisner and colleagues[1] very carefully reviewed
this issue and found that the available studies do provide some
indication that both tricyclics and selective serotonin reuptake
inhibitors (SSRIs) do not appear to cause any major problems for either
the course of the pregnancy or the infant. However, there have been no
definitive studies of this issue. So, where does that leave the
physician and patient who are trying to decide what to do?
The decision-making process greatly depends on the clinical situation.
For a pregnant patient with a new episode of major depression that is
mild or moderate in severity, it would probably be best to initially
pursue psychotherapy. Pharmacotherapy should then be considered as a
possibility if psychotherapy does not produce a remission of symptoms.
Additionally, pharmacotherapy may be an option if the patient has had a
previous episode of major depression for which psychotherapy was
ineffective and pharmacotherapy was effective. For a pregnant patient
presenting with severe symptoms, the issue becomes much more difficult.
Psychotherapy has not been shown definitively to be effective for severe
episodes of major depression. In addition, untreated or ineffectively
treated depression confers potential morbidity for the woman and her
unborn child, including poor weight gain or weight loss in the mother
and low birth weight for the child. With the emerging indications that
antidepressants likely do not cause major problems during pregnancy,
pharmacotherapy should be considered as an option for the severely
depressed pregnant patient.
Patients who become pregnant while being treated with an antidepressant
also face a difficult choice. If the treatment has just started or has
not produced a remission of symptoms, strong consideration should be
given to discontinuing the antidepressant and trying a course of
psychotherapy. If the pharmacotherapy is beyond the acute phase, having
produced a remission of symptoms, the decision should be based on the
initial severity of the depression symptoms and the length of
continuation therapy that has been reached. Most depression treatment
guidelines recommend a continuation phase of treatment of 4-9 months
after remission of symptoms is attained. Early discontinuation of
continuation therapy carries a very significant risk of recurrence of
the depression. This is therefore one of those situations where the
risks and benefits of treatment must be very carefully weighed with the
patient. If the depression was relatively mild and/or the continuation
phase almost completed anyway, it would make sense to discontinue the
antidepressant, while observing the patient very closely for signs and
symptoms of a recurrence. However, continuation of the antidepressant
may be the best option if the depression was severe and difficult to
treat, if the treatment is still in the early continuation phase, or if
the patient had a previous episode of depression that was severe and
difficult to treat or that recurred when treatment was discontinued.
For patients being treated with an antidepressant who desire to become
pregnant, the best advice would be to wait until the treatment is
completed. This is a problem largely with patients who have had
recurrences of major depression or who have other, chronic forms of
depression requiring long-term maintenance therapy. Psychotherapy has
not been shown to be effective as monotherapy for maintenance, although
it may be effective at delaying a recurrence in this setting. One
approach might be to delay the pregnancy as long as possible and to
taper off the antidepressant while beginning psychotherapy to try to
prevent a recurrence. The patient could then be monitored very closely
for recurrence of depressive symptoms, at which time pharmacotherapy
could be reconsidered.
In all of these situations, a joint decision-making process is
essential. The provider must carefully provide the patient with the
available information about the risks and benefits of treatment, and the
patient must make the final decision. Very careful documentation of this
process is also essential.
Whatever the risk to the child, a major part of the decision (which should
include the OB/GYN and Psychopharm talking with each other) is the risk to the
mother's mental health if she goes OFF the meds she is on. Also, I wonder if
there would be risks to the fetus if the mother is taken off certain drugs,
like the ones developed as antiseizures, like Depakote. MMM, interesting
question! Manic Depression/Depression links, books, treatments, meds:
http://www.geocities.com/postcard_Cathy
I always read that ECT is the safest depression treatment for pregnant women.
Because ECT uses no drugs exept for the brief anesthesthia...the mother doesnt
pass along SSRIs or other psychiatry drugs to her infant. ECT is considered very "clean" in that respect.
Thoughts on quackery. "Never forget one of health care's most important rules:
it's never wrong to ask questions. Anyone who makes you think otherwise may
well be a quack."
http://groups.yahoo.com/group/FactsAndFallaciesOfDepression Makes sense, Eric, as ECT is described as inducing a seizure. In 1981, I
miscarried and had an Epileptic seizure all at the same time (neither had
anything to do with each other). So when I had become pregnant again in
late-1983, an EEG was done to check me out again. It was more a patient
pacifier than anything. I checked out fine. The 1981 episode was just a odd
happening. Just like if one happened today. But in 1983, I was scared that
it would happen again. I'm sure a lot of women have had seizures when
pregnant. I don't personally know any, but there must be some.
