How to Safely Treat Depression During and After Pregnancy

Utilization of psychotropic medications during the peripartum period can be a difficult and personal decision, as medication-induced risks to the unborn child must be weighed against the risk of untreated mental illness. During the Neuroscience Education Institute Max! Virtual Meeting, Andrew J. Cutler, MD, a clinical professor in the Department of Psychiatry at SUNY Upstate Medical, discussed treatment options for women with mental illness during and post-pregnancy.

“This is a very common issue,” said Dr. Cutler. The prevalence of mood disorders during pregnancy is relatively high, occurring in 7.4% of women in the first trimester, 12.8% in the second trimester, and 12.0% in the third trimester.

The benefit versus risk of treatment with antidepressants during pregnancy needs to be weighed, as untreated depression is associated with inadequate maternal weight gain, preeclampsia, fetal distress, postpartum depression, and more. However, antidepressant use poses risks for the fetus, including cardiac defects, autism, major malformation, and more. “There is a difficult balancing act we have to undergo,” said Dr. Cutler.

Children born to mothers who have been depressed during pregnancy have higher impulsivity; maladaptive social interactions; and cognitive, behavioral, and emotional difficulties. Untreated mothers have a greater risk of suicide, complications, and engagement in high-risk behaviors such as smoking and poor nutrition.

The American College of Obstetricians and Gynecologists (ACOG) says women should be screened for depression and anxiety symptoms at least once during pregnancy.

“Antidepressants are safer than we thought in the past,” said Dr. Cutler, and the prevalence of selective serotonin reuptake inhibitors use during pregnancy is 3% to 7%. “Untreated depression is probably more concerning than use of antidepressants,” he said.

Other nonpharmacologic interventions include repetitive transcranial magnetic stimulation, exercise, folate, bright light therapy, massage, and acupuncture.

When discussing the postpartum period, Dr. Cutler said physicians must distinguish between “baby blues,” which occurs in 75% of mothers, versus postpartum depression (PPD), which occurs in 20% of women. About 25% to 40% of women with PPD have a prior history of depression, which is why screening is so important, he said.

Risk factors for PPD include:

  • Anxiety and depression during pregnancy
  • Previous episode of PPD
  • Previous history of depression
  • Heightened hypothalamic-pituitary-adrenal axis sensitivity to hormonal changes
  • Unwanted pregnancy
  • Experiencing stressful life events during pregnancy or the early postpartum period
  • Low levels of social support

The U.S. Preventive Services Task Force and ACOG recommend screening for depression at least once during the postpartum period. There are mixed results regarding the impact of using antidepressants to prevent PPD, and there is insufficient evidence to say whether, and for whom, antidepressant or psychosocial treatments are more effective.

When initiating women on antidepressants, screen all patients diagnosed with PPD for evidence of bipolar disorder. Antidepressants should be used with caution in antidepressant-naïve women who experience their first depressive episode in the postpartum period. Caution also needs to be exercised while using antidepressants in women who have mixed depression. Antidepressants should be tapered if the patient develops postpartum psychosis, and treatment should be carried out with initiation/optimization of mood stabilizer or atypical antipsychotic with mood stabilizing properties. For breastfeeding mothers, most studies of infant exposure to antidepressants show low levels of drug in breast milk and infant serum. Dr. Cutler advises against breastfeed while taking these agents.

Brexanolone is the first FDA-approved agent for the treatment of PPD in adult women. It is administered over 60 hours via a single continuous intravenous infusion and has demonstrated “dramatic” reductions in depressive symptoms within 24 hours for many patients, with a response that is sustained for 30 days. Common adverse events (AEs) include somnolence, dizziness, and sedation. There is now an oral drug approved for PPD, zuranolone, which is associated with a response rate of 72% (compared with 48% with placebo) and a remission rate of 45% (compared with 23% with placebo). Common AEs include somnolence/sedation, dizziness, upper respiratory infection, and diarrhea. “These are two exciting developments in the treatment of PPD,” said Dr. Cutler.

He advised that pediatricians may be the only constant contact a woman has with a physician during the first year postpartum, so these physicians should be screening for PPD. The American Academy of Pediatrics recommends screening for PPD at one, two, and four months, although 70% of pediatricians report never screening for PPD.

Presentation: Maternal Mental Health: Addressing Peri– and Postpartum Depression. Presented at the Neuroscience Education Institute Max! Virtual Meeting, Nov. 5-8, 2020.