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Complementary and Alternative Medicine Therapies for Depression during Pregnancy

Complementary and Alternative Medicine Therapies for Depression during Pregnancy

Approximately 18% of women suffer from perinatal depression.1  Untreated prenatal depression is associated with obstetrical and neonatal complications2-7 and is a strong risk factor for postpartum depression.8   Postpartum depression has been associated with negative effects on child development.   In spite of the risks of untreated perinatal depression, women often discontinue antidepressant treatment during attempts to conceive or during pregnancy.  Safety profiles of antidepressant use during pregnancy are increasingly being studied, though women often seek alternatives during pregnancy.  More than a quarter of women report the use of a complementary and alternative medicine (CAM) therapy during pregnancy.9  Despite the prevalence of CAM use, the number of adequately powered, well-designed controlled clinical trials of CAM treatments for prenatal depression is limited.  This article will review several CAM treatments for prenatal unipolar depression: omega-3 fatty acids, folate, St. John’s Wort, bright light therapy, massage therapy and exercise.  

Omega-3 Fatty Acids
Omega-3 fatty acids are among the most commonly used CAM treatments in the United States.10  Omega-3 fatty acids, including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are essential fatty acids with well-established health benefits and particular benefits for obstetrical outcomes and infant development.11,12  Consensus guidelines recommend pregnant women consume at least 200 mg of DHA daily13 to optimize pregnancy outcomes and fetal health.

Meta-analyses of randomized controlled trials (RCTs) demonstrate a significant antidepressant benefit of omega-3 fatty acids in mood disorders overall, especially when used as augmentation to antidepressants.  However, some RCTs assessing the effectiveness of omega-3 fatty acid supplementation have not demonstrated a benefit in acute treatment or prevention of perinatal depression.14-16  The Omega-3 Fatty Acids Subcommittee, assembled by the American Psychiatric Association, recommends patients with depression take 1 gram EPA + DHA daily.  Current evidence may support the use of 1-9 g supplement of EPA + DHA daily for patients with mood disorders, though use of greater than 3 g daily should be monitored by a physician due to possible anticoagulant effects at higher doses.17   Based on positive findings from RCTs and meta-analyses in non-perinatal depression, pregnant patients with depression may consume 1 gram EPA + DHA daily as augmentation of other conventional depression treatments but there is little evidence of efficacy as monotherapy.

Folate
Folate, available as folic acid, folinic acid and 5-methyltetrahydrofolate or L-methylfolate, is important in the synthesis of nucleic acids and amino acid metabolism.  Many studies report an association of low folate levels and an increased risk of depression18-20 and low blood folate has been associated with a poorer response to treatment with antidepressants in major depression.21  Epidemiological data, however, do not demonstrate that higher folate intake during pregnancy lessens the risk of the development of postpartum depression.22  Folate and L-methylfolate have been best studied as augmentation strategies to concomitant antidepressant treatment in non-perinatal depression.23,24 

To reduce the risk of neural tube birth defects, women of reproductive age are recommended to consume 0.4-1mg folic acid daily.  There have been no studies published on the efficacy of folate monotherapy or augmentation therapy for depression during pregnancy.  Considering the potential decrease in birth defects and RCT data that mainly support a positive effect of antidepressant augmentation with folate (i.e. folic acid 0.4-5mg/day or folinic acid 15-30mg/day), folate can be an important adjunctive strategy for prenatal depression that carries little risk and may be especially effective in whose women with low serum folate levels. 

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