Treating pregnant women with clinical depressive symptoms poses a difficult
challenge to not only obstetricians and psychiatrists but also to the patients
themselves. Specialists in both disciplines have worked together to review the
literature and produce a report with practical guidance.
In a collaborative effort, APA and the American College of Obstetricians
and Gynecologists (ACOG) convened a work group of psychiatrists and
obstetricians/gynecologists led by Kimberly Yonkers, M.D., an associate
professor of psychiatry and obstetrics, gynecology, and reproductive sciences
at Yale School of Medicine. The work group examined available research and
formulated recommendations on how to best manage depression during pregnancy.
The report has been published simultaneously in the September Obstetrics
and Gynecology and the September/October General Hospital
Depressive symptoms are present in 14 percent to 23 percent of pregnant
women and, if left untreated, can pose serious risks to the health and
well-being of both the patient and the fetus she carries, according to the
report. Although researchers have examined the risks of antidepressant
exposure to birth outcomes to a certain extent, many studies have produced
conflicting or inconsistent results. There are even fewer data on the effects
of maternal depression on pregnancy and child developmental outcomes.
Published studies are often hampered by uncontrolled confounding factors and
small sample size.
"There are no clear-cut data [to quantify] the risk of antidepressant
treatment independent of the underlying illness," said Yonkers in an
interview with Psychiatric News. Although some antidepressants have
been linked to a small but significant increase in adverse risks, studies have
not been able to extricate the effect of medications from the effect of
depression itself, she pointed out.
The work group devised antidepressant treatment algorithms and guidelines
to help physicians make optimal, individualized therapeutic decisions with
A thorough assessment of a patient's current symptoms and medical history
is critical for determining the treatment strategy over the course of
pregnancy, the group recommended. Physicians are urged to consider
psychosocial treatments, especially cognitive-behavioral therapy and
interpersonal psychotherapy, for patients with mild-to-moderate depression,
especially for women who are planning to become pregnant or who would rather
avoid antidepressant medications.
In contrast, patients with a history of severe and/or recurrent depression,
psychotic symptoms, bipolar disorder, or a suicide attempt should not be
discontinued from drug therapy.
Electroconvulsive therapy is an option for inducing rapid symptom relief
for pregnant women who have not responded to antidepressants or other therapy
or who are psychotic, suicidal, or severely disabled.
The work group strongly calls for obstetricians and psychiatrists to
coordinate their care, especially for patients who require careful monitoring
and evaluation as their conditions and symptoms fluctuate. Further,"
respect for the patient's preferences is paramount," the report
The overarching message is "there isn't one simple answer,"
according to Yonkers. "A collaborative approach involving the
psychiatrist, the obstetrician, and the patient is the best. There is no one
scenario that fits every patient."
Nada Stotland, M.D., M.P.H., immediate past president of APA and an expert
in reproductive psychiatry, is a coauthor of this report.
"Depression during pregnancy is a particularly common and vexing
clinical problem," Stotland told Psychiatric News."
Untreated depression is bad for the pregnancy and a risk for postpartum
depression, which is agonizing for the mother and harmful for the baby. The
collaboration between APA and ACOG brought both perspectives and bases of
knowledge to the work on this paper and will bring this important information
to clinicians in both specialties. I hope this project will be a model for
many collaborations in the future."
"The Management of Depression During Pregnancy: A Report From
the American Psychiatric Association and the American College of Obstetricians
and Gynecologists" can be accessed at<http://journals.lww.com/greenjournal/pages/default.aspx>.▪