Unipolar major depression in pregnant women: General principles of treatment
- Sophie Grigoriadis, MD, MA, PhD, FRCPC
Sophie Grigoriadis, MD, MA, PhD, FRCPC
- Associate Professor of Psychiatry
- University of Toronto
- Sunnybrook Health Sciences Centre
- Section Editors
- Peter P Roy-Byrne, MD
Peter P Roy-Byrne, MD
- Editor-in-Chief — Psychiatry
- Section Editor — Depressive Disorders
- Professor of Psychiatry and Behavioral Sciences
- University of Washington School of Medicine
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
Unipolar major depression is common in pregnant women, but is often not treated . In a nationally representative survey in the United States that identified pregnant women with major depression, only 50 percent received treatment . Untreated disease causes maternal suffering and is associated with poor nutrition, comorbid substance use disorders, poor adherence with prenatal care, postpartum depression, impaired relationships between the mother and her infant and other family members, and an increased risk of suicide [3,4].
Barriers to treatment of antenatal depression include cost, opposition to treatment (eg, fear of exposing the fetus to antidepressant medication or lack of interest in psychotherapy), unavailability of psychotherapy, and stigma [3,4]. In addition, many clinicians are reluctant to use pharmacotherapy because they lack sufficient expertise , and the large literature is often inconsistent .
This topic reviews the general principles of treating antenatal unipolar major depression. Other topics discuss choosing a specific treatment for antenatal major depression; the risks of antidepressants during pregnancy; and the epidemiology, clinical features, assessment, and diagnosis of antenatal depression.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Vigod SN, Wilson CA, Howard LM. Depression in pregnancy. BMJ 2016; 352:i1547.
- Ko JY, Farr SL, Dietz PM, Robbins CL. Depression and treatment among U.S. pregnant and nonpregnant women of reproductive age, 2005-2009. J Womens Health (Larchmt) 2012; 21:830.
- ACOG Committee on Practice Bulletins--Obstetrics. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists number 92, April 2008 (replaces practice bulletin number 87, November 2007). Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol 2008; 111:1001.
- Stewart DE. Clinical practice. Depression during pregnancy. N Engl J Med 2011; 365:1605.
- Osborne LM, Hermann A, Burt V, et al. Reproductive Psychiatry: The Gap Between Clinical Need and Education. Am J Psychiatry 2015; 172:946.
- LaRusso EM, Freeman MP. Antidepressants in pregnancy. In: Clinical Pharmacology During Pregnancy, Mattison DR. (Ed), Elsevier, London 2013. p.295.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
- Chaudron LH. Complex challenges in treating depression during pregnancy. Am J Psychiatry 2013; 170:12.
- National Institute for Health and Care Excellence (NICE). Antenatal and postnatal mental health: clinical management and service guidance. NICE clinical guideline 192. December 2014. http://www.nice.org.uk/guidance/cg192 (Accessed on January 28, 2016).
- Goodman JH. Women's attitudes, preferences, and perceived barriers to treatment for perinatal depression. Birth 2009; 36:60.
- Melville JL, Reed SD, Russo J, et al. Improving care for depression in obstetrics and gynecology: a randomized controlled trial. Obstet Gynecol 2014; 123:1237.
- Grote NK, Katon WJ, Russo JE, et al. COLLABORATIVE CARE FOR PERINATAL DEPRESSION IN SOCIOECONOMICALLY DISADVANTAGED WOMEN: A RANDOMIZED TRIAL. Depress Anxiety 2015; 32:821.
- Ngai FW, Chan SW, Ip WY. The effects of a childbirth psychoeducation program on learned resourcefulness, maternal role competence and perinatal depression: a quasi-experiment. Int J Nurs Stud 2009; 46:1298.
- Hayes BA, Muller R, Bradley BS. Perinatal depression: a randomized controlled trial of an antenatal education intervention for primiparas. Birth 2001; 28:28.
- Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry 2009; 31:403.
- American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition (supplement). Am J Psychiatry 2010; 167:1.
- American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition. October, 2010. http://psychiatryonline.org/guidelines (Accessed on February 13, 2016).
- National Institute for Health and Care Excellence (NICE). Depression: The Treatment and Management of Depression in Adults (Updated Edition). Clinical Guideline 90. October, 2009. http://www.nice.org.uk/guidance/cg90 (Accessed on February 13, 2016).
- Parikh SV, Segal ZV, Grigoriadis S, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. J Affect Disord 2009; 117 Suppl 1:S15.
- Yonkers KA, Blackwell KA, Glover J, Forray A. Antidepressant use in pregnant and postpartum women. Annu Rev Clin Psychol 2014; 10:369.
- Meltzer-Brody S, Jones I. Optimizing the treatment of mood disorders in the perinatal period. Dialogues Clin Neurosci 2015; 17:207.
- Koren G, Nordeng H. Antidepressant use during pregnancy: the benefit-risk ratio. Am J Obstet Gynecol 2012; 207:157.
- Stuart S, Koleva H. Psychological treatments for perinatal depression. Best Pract Res Clin Obstet Gynaecol 2014; 28:61.
- Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150:782.
- Committee on Obstetric Practice. The American College of Obstetricians and Gynecologists Committee Opinion no. 630. Screening for perinatal depression. Obstet Gynecol 2015; 125:1268.
- El-Den S, O'Reilly CL, Chen TF. A systematic review on the acceptability of perinatal depression screening. J Affect Disord 2015; 188:284.
- Cox J, Holden J, Henshaw C. Perinatal Mental Health: The Edinburgh Postnatal Depression Scale (EPDS) Manual, Second Edition, RCPsych Publications, London 2014.
- Wisner KL, Sit DK, McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry 2013; 70:490.
- Andrade SE, Raebel MA, Brown J, et al. Use of antidepressant medications during pregnancy: a multisite study. Am J Obstet Gynecol 2008; 198:194.e1.
- Mitchell AA, Gilboa SM, Werler MM, et al. Medication use during pregnancy, with particular focus on prescription drugs: 1976-2008. Am J Obstet Gynecol 2011; 205:51.e1.
- Reminick A, Cohen S, Einarson A. Managing depression during pregnancy. Womens Health (Lond) 2013; 9:527.
- Byatt N, Deligiannidis KM, Freeman MP. Antidepressant use in pregnancy: a critical review focused on risks and controversies. Acta Psychiatr Scand 2013; 127:94.
- Chisolm MS, Payne JL. Management of psychotropic drugs during pregnancy. BMJ 2016; 532:h5918.
- Cohen LS, Wang B, Nonacs R, et al. Treatment of mood disorders during pregnancy and postpartum. Psychiatr Clin North Am 2010; 33:273.
- Ray S, Stowe ZN. The use of antidepressant medication in pregnancy. Best Pract Res Clin Obstet Gynaecol 2014; 28:71.
- Robakis TK, Williams KE. Biologically based treatment approaches to the patient with resistant perinatal depression. Arch Womens Ment Health 2013; 16:343.
- Deligiannidis KM, Byatt N, Freeman MP. Pharmacotherapy for mood disorders in pregnancy: a review of pharmacokinetic changes and clinical recommendations for therapeutic drug monitoring. J Clin Psychopharmacol 2014; 34:244.
- Larsen ER, Damkier P, Pedersen LH, et al. Use of psychotropic drugs during pregnancy and breast-feeding. Acta Psychiatr Scand Suppl 2015; :1.