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Joint APA-ACOG Algorithms for Treatment of Depression During Pregnancy

A groundbreaking collaboration provides useful advice on a clinically challenging problem.

Depression is common in women during the childbearing years, and psychiatrists and obstetricians alike can find it challenging to treat depression during pregnancy. A workgroup convened by the American Psychiatric Association and the American College of Obstetricians and Gynecologists, with input from a developmental pediatrician, has reviewed the literature and developed algorithms for treating women with depression who either are contemplating pregnancy or are already pregnant.

Many studies were confounded by elevated rates of substance use and poor prenatal care in depressed women. In some studies, depression itself was associated with higher rates of miscarriage, preterm birth, fetal growth problems, and developmental delay; however, the workgroup could not draw definitive conclusions about these possible links. Despite problems with confounding, the evidence suggested that antidepressants raised risks for miscarriage, low birth weight, transient neonatal symptoms, and persistent pulmonary hypertension of the newborn.

Highlights of the treatment algorithms are:

• Adequate treatment of depression is essential, ideally beginning before conception.
  
• Women with severe recurrent major depression who stop pharmacotherapy are at high risk for relapse.
  
• Psychotherapy (preferably cognitive-behavioral therapy or interpersonal psychotherapy) is recommended for treatment of mild-to-moderate depression during pregnancy.
  
• Clinicians and patients should make decisions about pharmacotherapy collaboratively.
  
• Electroconvulsive therapy is an option in severe depression.
  
• Patients with severe depression, acute suicidality, psychosis, or bipolar disorder should receive psychiatric referrals.
  

Comment: The collaboration by these two specialty groups is groundbreaking. Despite the limitations of a mixed literature and lack of randomized controlled trials, the treatment algorithms for various clinical scenarios are helpful. The workgroup does not recommend specific antidepressants as being safer in pregnancy but discusses the possibly higher risk of cardiac malformations with paroxetine. However, a recent study suggests that this increased risk may be a class effect of SSRIs in general (BMJ 2009 Sep 26; 339:b3569). Also, "psychotherapy," which comprises a multitude of treatments, has been little studied; moreover, empirically validated therapies (CBT and interpersonal psychotherapy) are not always available. Clinicians should certainly recommend psychotherapy, preferably of a validated type, for mild-to-moderate depression. However, they must also continue to monitor depressive symptoms and reevaluate the need for medication throughout pregnancy, especially as depression during pregnancy raises the risk for postpartum depression.

This article was simultaneously published in Obstetrics and Gynecology (2009 Sep; 114:703).

— Deborah Cowley, MD

Published in Journal Watch Psychiatry September 28, 2009

Citation(s):

Yonkers KA et al. The management of depression during pregnancy: A report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry 2009 Sep/Oct; 31:403.

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Reader Remarks:

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• Depression during pregnancy
  Jack Friedman, private clinic, 29 Sep 2009 1:54 PM EST
  There have been recent studies showing positive effects of exercise programs in postpartum depression. Is this included in your protocols?... [more]
• A response from JW Associate Editor Deborah Cowley
  Deborah Cowley, MD, Professor, Dept of Psychiatry & Behavioral Sciences, Univ of Washington School of Medicine, Seattle, 29 Sep 2009 6:30 PM EST
  Thank you for your comment. This work group was focused on developing evidence-based algorithms for treatment during pregnancy, not for... [more]
• Depression During Pregnancy
  Reed Schimmelfing, MSW, LICSW, 29 Dec 2009 6:17 PM EST
  It is understandable but unfortunate that such a limited scope of options were assessed in this work. The reader would... [more]
• Psychotherapy during the first trimester
  Violet A. Henighan, 8 Feb 2010 12:58 PM EST
  In the wake of Paxil's lost lawsuit and the findings of birth defects, wouldn't it be wise to help the... [more]