How to Treat Depression During Pregnancy
‘Do we use medication to treat depression during pregnancy or no?’ This is the question that every psychiatrist faces even when she or he doesn’t particularly specializes in reproductive psychiatry. The question applies equally for planned and unplanned pregnancies.
There are several scenarios that seem to repeat more commonly in clinical practice, and according to the situation, the psychiatrist might give a different advice. While the following are the most frequent scenarios, potential and present pregnancies should be discussed with the primary care physician, obstetrician and psychiatrist.
1. Patient has been diagnosed with depression, treated to a remission state for more than two years, would like to start planning for a family. The most common question asked is, if she should continue the treatment while conceiving or should stop it during the conception period. The ideal situation would be to conceive while off medication if the remission could be maintained. If the mother would like to be off medication, then the risks of relapse should be discussed as well as a plan to restart the medication if that relapse occurs.
The medications should be tapered off and not instantly stopped. If the patient would like to stay on medication to avoid the risk of relapse, then the regimen should be reviewed, and changes should be made towards less teratogenic alternatives ( i.e. switch from Paxil-category D to Prozac – category C).
Also, Depakote or Tegretol should be avoided as mood stabilizers, or high doses of Folic acid should be added to prevent potential neural tube related malformations (folic acid in doses of 4 mg, instead of the commonly used dose of 1 mg per day, used in pregnant women without mental illness).
2. A patient who has an unplanned pregnancy while on medication for depression is most likely to ask if she needs to change or stop the medication at that point. Usually when the pregnancy is confirmed the fetus is about 4 weeks old and the effect of the medication most likely already has taken place. In that situation the current consensus is to not change to a different medication in order to avoid exposure of the fetus to two antidepressants vs. only one.
3. A patient who is stable during the pregnancy on her antidepressants might ask if she should breastfeed or if she should change medication while breastfeeding. The most commonly researched antidepressant in breastfeeding is Zoloft, therefore this would be the medication of choice if the treatment targets postpartum depression. However, if the pregnancy and delivery went well on a different antidepressant (i.e. Cymbalta or Prozac) the most likely recommendation would be to continue the use of the same drug since the baby had an in utero exposure already.
4. During the pregnancy, the psychiatrist should counsel the mother that an increase in dosing might be necessary to keep symptoms in remission, because of increased volume of distribution, and the dose should be adjusted again before delivery and immediately postnatal. Because of the risk of inducing neonatal hypertension, some psychiatrists would decrease the SSRI dose in the same trimester, to decrease the risk.
While this is just a short review of using antidepressant in pregnancy, one should be aware of other biological treatments available, less invasive, such as TMS (transcranial magnetical stimulation) or light therapy, that could be a safe alternative to medications.