Evaluation and treatment (with psychotherapy, antidepressant therapy, or both) of women with depression during pregnancy are described in the latest article in our Clinical Practice series. Data on potential benefits and risks to mothers and offspring are reviewed; overall, they suggest that absolute risks are small.
Major depression is a common and treatable mental disorder and a major cause of disability. In population-based surveys, 7% of adults reported depression in the preceding 12 months and 12.7% reported depression during pregnancy.
• What are the risk factors for depression during pregnancy?
The strongest risk factor for depression during pregnancy is a history of depression. Other risk factors include a family history of depression or bipolar disorder, childhood maltreatment, single motherhood, having more than three children, cigarette smoking, low income, age younger than 20 years, insufficient social support, and domestic violence.
• What are the consequences for the mother of untreated depression during pregnancy?
The consequences of depression during pregnancy include difficulty performing usual activities and failure to seek prenatal care; inadequate diet; the use of tobacco, alcohol, and other harmful substances; and the risk of self-harm or suicide.
Morning Report Questions
Q: What are the risks of maternal depression for the infant?
A: Depression may affect fetal growth as well as infant temperament and later behavior. Infants of depressed mothers, as compared with mothers who are not depressed, have been reported to have increased irritability, fewer facial expressions, and higher cortisol levels and to be at risk for developmental delay.
Q: Which antidepressant medications are considered most appropriate for use during pregnancy?
A: In general, the choice of antidepressant should be based on the side-effect profile, the patient’s past response, and the agent with the lowest risk profile for the mother and fetus on the basis of available data. Selective serotonin-reuptake inhibitors (SSRIs) are similar to one another in efficacy, have fewer maternal and fetal side effects than tricyclic antidepressants, and are safer in overdoses than tricyclic antidepressants. Most studies have suggested similar risk profiles for SSRIs and selective noradrenergic reuptake inhibitors. Paroxetine should be avoided if possible, since among the SSRIs, it has the strongest association with cardiac malformations. Antidepressants should be started at the lowest effective dose and gradually increased as needed to achieve remission. Monotherapy is generally preferable.