Treatment Of Depression In Pregnancy
Hallie Bensinger, MSN, FNP, RNC
William Kutteh, MD, PhD.


According to the National Institute of Mental Health depression has a prevalence of about 20.9 million American adults (7%). Depression can be mild, moderate or severe and affects women more often than men. Hormonal changes related to a woman’s menstrual cycle, pregnancy, the post-partum period, pre-menopause and menopause may also contribute to increased rated of depression in women. External stressors from work and home can also contribute to depression, and people who have a family history of depression may be at increased risk for the disease.

Treatment is possible. The first line of defense against the disease is a class of medicine known as serotonin reuptake inhibitors, or SSRI. These medications, in combination with psychotherapy, can be very effective in the treatment of depression. Below is a table of brand and generic names of common SSRI’s.

A second class of medications called serotonin norepinephrine reuptake inhibitors (SNRI) can also be beneficial. Below is a table of SNRI brand and generic names.
 

However, recent studies have determined that SSRI’s may not be safe to take in pregnancy and can actually cause heart defects in the developing baby. Two studies have suggested that Paxil (paroxetine) specifically may have up to a two-fold increase risk for the infant to have a cardiac defect.

In addition to concerns about heart defects exposure to SSRI’s late in pregnancy has been associated with neonatal complications, including jitteriness, mild respiratory distress, transient tachypnea [rapid breathing], weak cry, poor [muscle] tone, and admission to a neonatal intensive care unit. An even more serious risk is that of a six-fold increase in the baby developing persistant pulmonary hypertension (which can be life threatening) in pregnancies exposed to SSRI’s after 20 weeks gestation.

Because of these risks of defects and complications, the Federal Food and Drug Administration has changed the safety category of Paxil from a category C (meaning that drugs in this category can cause defects in animals but have not been studied adequately in humans) to a category D (meaning that the drug has been found to cause birth defects in humans).

Because of the potential risks involved with these drugs and because of the structural similarity of many of these medications to Paxil, we recommend that women planning to become pregnant discuss these issues with their therapist prescribing the medication. Ideally, one should wean off of SSRI’s under the guidance of her physician or switch to a drug safer to take in pregnancy prior to conception. Buproprion (Wellbutrin) may be a safer alternative although this has not been conclusively proven. This medication is from a different class and has a Pregnancy Category rating of “B” (meaning that the drug has been tested in animals with very low risks and there have been no reports of risks to human pregnancies). You may wish to discuss this with your physician. We also strongly encourage psychotherapy in individuals suffering from depression.

In summary, depression is a real illness. Women who are clinically depressed during their pregnancy “may increase their risk of low weight gain, sexually transmitted diseases, and alcohol and substance abuse,” (1) all of which can indicate complications for mother and baby. If you are suffering from depression, we along with the American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice recommend the avoidance of Paxil during pregnancy. If you are taking other SSRI’s or SNRI’s talk to your primary care provider about switching to a safer drug in pregnancy or weaning off the medication. These medications should never be stopped abruptly because of potential dangerous withdrawal effects. Help us help you have a healthier mom and baby.

References:
ACOG Committee Opinion. Treatment with selective serotonin reuptake inhibitors during pregnancy. Obstetrics and Gynecology 2006; 108:1601—02.
Schneider, M.E. ACOG advises against Paxil in pregnancy. OB/Gyn News 12-15-2006; 4a-b.
http://www.nimh.nih.gov/publicat/depression.cfm. Depression updated 9/13/2006.


HMB doc 2/12/07