Depression During Pregnancy

Major depressive disorder (MDD) is common during childbearing. Depression that interferes with function develops in an estimated 14.5% of pregnant women.¹ In a recent population-based study, Munk-Olsen and colleagues² determined the prevalence of psychiatric disorders relative to childbearing. The overall risk for any psychiatric episode after delivery was elevated for women during the first 3 postpartum months. However, the increased risk specifically for major depression remained elevated for 5 months after birth. These statistics are troubling in that only 13.8% of pregnant women who screen positive for depression actually receive treatment.³

MDD is associated with substantial perinatal risk directly related to the physiological sequelae of maternal psychiatric illness. Hypothalamic-pituitary-adrenal axis hyperactivity may directly affect fetal growth and increase corticotropin-releasing hormone release from the placenta, which affects the timing and onset of delivery.⁴ Furthermore, women with depression have a 2.5-fold increased risk for preeclampsia during pregnancy.⁵

Maternal health behaviors associated with MDD (such as cigarette and substance use, poor adherence to obstetrical care, deficient nutritional intake, and social isolation) increase the risk for poor pregnancy outcome.^6,7 Although rare, maternal suicide attempts (which occur in 0.4 per 1000 pregnancies) are another potential complication of MDD.⁸ Fetal exposure to MDD has an adverse impact on later child development that is independent from the child’s exposure to maternal postpartum depression.⁹

These observations support consideration of maternal MDD as a potent risk factor to the mother, fetus, and family. Identification and treatment of depression during pregnancy deserves to be a public health priority to reduce the health burden for women, families, and communities.¹⁰

In this article, I discuss general principles of treatment of MDD during pregnancy, evidence-based treatments for outpatient care (psychotherapy, SSRI pharmacotherapy, electro-convulsive therapy [ECT], and morning bright light treatment), and the proposed FDA classification system for drug use during pregnancy.

Approach to intervention during pregnancy

According to principles of risk-to-benefit decision making during pregnancy, the patient is responsible for stating her preferences regarding the treatment options offered by the physician and for making a thoughtful choice.¹¹ The major focus of treatment is typically maternal symptom reduction; however, a broader concept of optimizing pregnancy outcome is preferable.¹² The physician must communicate information about risks, which is frequently challenging (Table).^11,13,14

Ideally, women and their psychiatrists can select from a variety of treatment options for MDD; however, evidence-based mental health treatments are not universally accessible. Availability, acceptability, and cost (and, unfortunately, often limitations) must factor into the choice of treatment. The fragmentation of health care for young women also makes identification of a specific physician as a point of responsibility difficult.^15,16 Moreover, depressed patients identified in primary care settings rarely complete referrals for mental health treatment. Newer models, such as collaborative care—an approach based on chronic disease management principles combined with experienced nonmedical specialists working with the primary care physician and mental health professional—have emerged and have been applied to care for childbearing women.^17,18