When clinically feasible, nondrug treatments for depressed pregnant women are desirable to avoid fetal medication exposure. The standard evidence-based options are psycho-therapy and antidepressant medication or a combination of the two. ECT is also effective. A reasonably well-studied nondrug environmental intervention for MDD is morning bright light therapy.19
In the dynamic state of pregnancy, treatment efficacy can be affected by dramatic physiological and metabolic changes. Systematic monitoring with a repeated self-report or clinician-administered scale provides useful data throughout the pregnancy. Serial ratings can be used to assess response to an intervention and evaluate the need for additional therapies.
A practical and rapid clinician-administered measure is the Clinical Global Impressions Scale, a 7-point global severity and change scale.20 The Edinburgh Postnatal Depression Scale (EPDS), a 10-item self-report, has also been validated as a screening tool for depression during pregnancy. The EPDS has also been used successfully to assess response to a psychotherapeutic intervention21; a score of 15 or higher is associated with probable major depression during pregnancy.22
Although psychotherapy is not readily available in all practice settings, clinical experience shows that short-term therapies, such as cognitive-behavioral therapy, are effective during pregnancy. Spinelli and Endicott22 undertook a 16-week clinical trial to compare interpersonal psychotherapy for depression during pregnancy with a didactic parenting education (control) program. Thirty-eight pregnant women were included in the analysis. Outcome measures were based on the EPDS, the Beck Depression Inventory, and the Hamilton Rating Scale for Depression. Women who were randomized to either the interpersonal psychotherapy group or the control group showed some improvement, but women in the interpersonal psycho-therapy group showed greater improvement on all measures. The investigators concluded that interpersonal psychotherapy is effective and should be a first-line treatment in the hierarchy of therapies for antenatal MDD. This recommendation is consistent with expert recommendations and clinical wisdom.23
Freeman and colleagues24 also found benefits of supportive psycho-therapy. The investigators undertook a pilot investigation in antenatal women with MDD who were randomized to receive omega-3 fatty acids and provided manualized supportive psychotherapy. Their results showed no significant difference between omega-3 fatty acids and placebo; however, the manualized supportive psychotherapy was found to be effective.
If psychotherapy is not associated with a response, or if the depressive episode is severe, combination psychotherapy and antidepressant pharmacotherapy is warranted.23
SSRI pharmacotherapy is common among childbearing-aged women. An estimated 92,000 pregnant women are exposed to these agents each year.25 Many women who benefit from maintenance pharmacotherapy for recurrent MDD choose to continue treatment throughout pregnancy. Others elect a trial off medication around the time of conception. Pregnant women who discontinue antidepressant medication have a higher risk of relapse (68%) than those who maintain treatment (26%).26
With the first signs of depressive symptoms indicative of relapse, resumption of medication is advisable. From a clinical standpoint, tapering medication and instituting psycho-therapy is a reasonable strategy; however, no data are available to support the mitigation of recurrence risk.23
A woman’s treatment history is a primary criterion for drug selection. Previous response to a specific antidepressant with tolerable adverse effects is crucial information to support use of that agent for the individual patient. Switching from an effective agent to another drug risks nonresponse (with exposure to MDD and its sequelae for the mother and fetus) as well as potential new adverse effects. The use of alcohol(Drug information on alcohol) and other drugs (including nonprescription drugs and smoking) during pregnancy must be documented by the physician before prescribing an antidepressant to avoid automatic implication of the antidepressant as causal if the outcome is negative.27