Depression in Pregnancy

Background

Depression is one of the most common complications of the perinatal period, affecting up to 20% of women antenatally and approximately 15% of women postpartum.¹ A number of risk factors for depression have been previously identified (Table 1).² ACOG recommends screening all women for depression “at least once” during pregnancy and postpartum with a validated tool. Women at elevated risk for depression may benefit from more frequent screening. This has not been well studied. Per ACOG, “Women with current depression or anxiety, a history of perinatal mood disorders, risk factors for perinatal mood disorders, or suicidal thoughts warrant particularly close monitoring, evaluation, and assessment.”³ Screening may be of therapeutic benefit in and of itself, and allows for identification of women who would benefit from lifestyle interventions, counseling, and/or pharmacotherapy.⁴ Any woman with a past history of depression may benefit from outright counseling or psychotherapy for prevention of postpartum depression.⁵

Table 1. Risk factors for perinatal depression2
Antenatal depression	Postpartum depression
Anxiety Life stress and history of trauma History of depression Lack of social support Unintended pregnancy Medicaid or uninsured Domestic violence Low income Low educational attainment Smoking Unpartnered Poor relationship quality	Past history of depression or PPD Depression in pregnancy Anxiety in pregnancy Stressful life events during pregnancy or      postpartum Traumatic delivery NICU admission Low social support Lactation difficulties Family history of PPD

Depression screening

Figure 1. Antenatal depression screening

Figure 2. Antepartum anxiety screening

Figure 3. Postpartum depression and anxiety screening

Treatment of maternal mood disorders

Treatment options:

1. Nonpharmacologic therapy: First line⁶
   1. Counseling referral
      1. Standard of care: psychotherapy or cognitive behavioral therapy (CBT)
         1. Psychiatry referral (Ambulatory Referral to Connect Center)
         2. Locate provider through psychologytoday.com
         3. County Mental Health
      2. Internet-based counseling likely effective⁷ 
   2. Lifestyle modifications: 
      1. Enlist support
      2. Sleep⁸
         1. Sleep hygiene
         2. Sleep aids prn (unisom, trazodone, seroquel)
      3. Exercise⁹ (walking, yoga)
      4. Refer to Postpartum Support International (https://www.postpartum.net/) or Mass General Center for Women’s Mental Health for more resources (https://womensmentalhealth.org/resource-2/patient-support-services/)

 

1. Medication therapy:
   1. Counsel on risks of medication therapy (Table 2) compared to risks of untreated depression and anxiety (Table 3)
   2. Screen for history of mania – if present, do not start SSRI and needs psychiatry referral
      1. “Some people have periods lasting several days or longer when they feel much more excited and full of energy than usual. Their minds go too fast. They talk a lot. They are very restless or unable to sit still and they sometimes do things that are unusual for them, such as driving too fast or spending too much money. Have you ever had a period like this lasting several days or longer?”
      2. “Have you ever had a period lasting several days or longer when most of the time you were so irritable or grouchy that you started arguments, shouted people, or hit people?”
      3. If yes to either: “People who have episodes like this often have changes in their thinking and behavior at the same time, like being more talkative, needing very little sleep, being very restless, going on buying sprees, and behaving in ways they would normally think are inappropriate. Did you ever have any of these changes during your periods of being excited and full of energy or very irritable and grouchy?”
         1. If yes, SCREEN POSITIVE. Refer to psychiatry, do not start SSRI.
         2. If no, screen low risk for bipolar.
2. Psychiatry evaluation:
   1. Epic order: ambulatory referral to connect center, and click on the “Perinatal Psychiatry” button
   2. Perinatal psychiatry availability (all offering telehealth):
      1. Dr. Neha Hudepohl (based at GMH/Patewood)
      2. Dr. Jessica Obeysekare (based at Greer)
      3. Jennifer Clark, NP (based at GMH/Patewood)
      4. Resident perinatal psychiatry clinic at OBGYN Center
      5. Resident perinatal psychiatry clinic at Brownell Center
3. Emergency considerations:
   1. If endorse active suicidal/homicidal ideation, the patient needs URGENT care. 
      1. MIP, 830 am – 7 pm, M-F: 864-455-8988
      2. Emergency Department

Table 2. Risks of SSRI use in pregnancy10
SAB	Risk not increased
Stillbirth	Risk not increased
Congenital malformations	Likely not an increased risk; no consistent malformation risk has been identified.  Paroxetine may confer slightly increased risk cardiac malformations, though recent data argues against this association
Preterm birth	Risk is increased but same as in untreated depression
Low birth weight	Risk is increased but same as in untreated depression
Neonatal adaptation syndrome	10-30% of exposed pregnancies Lasts < 2 days Jitteriness, fussiness, tachypnea, poor feeding Does not typically prolong hospital stay Risk does not decrease from discontinuation of SSRI in third trimester
Persistent pulmonary hypertension of the newborn	Yes - 2-fold increased risk  Absolute risk remains very low (0.2% of exposed pregnancies) Untreated maternal depression is also a risk factor

 

Table 3. Risks of untreated maternal mood disorders6,10
Illness	Obstetric impact	Neonatal impact
Anxiety	Increased operative deliveries Prolonged labor Precipitate labor Preterm birth SAB Fetal distress	Decreased developmental scores Poor adaptability Lower developmental scores at age 2
Major depression and bipolar disorder	Increased low birth weight Poor fetal growth Postnatal complications	Increased newborn catecholamine and cortisol Increased infant crying Increased NICU admission Increased developmental delay Increased mental health disorders in offspring Increase cognitive and school performance issues in childhood and adolescence

 

Medication therapy:

Has patient used an effective SSRI previously?⁶

1. Yes: Re-initiate effective agent
2. No: consider sertraline or selection of SSRI based on symptom profile and patient preference (Table 4)

• If poor results with SSRI or poor tolerance, consider SNRI (2nd line - most data with Effexor), atypical (ie buproprion), or tricyclic antidepressant (3rd line) with psychiatry assistance
  1. If already on alternative pharmacotherapy with good control, counsel on available data with caveat of less data on non-SSRI pharmacotherapy
  2. Consider that individuals with anxiety may require higher doses of SSRI for adequate therapeutic effect than those with depressive symptoms alone

Table 4. SSRI Choice
SSRI	Dosing	Clinical considerations
Sertraline (Zoloft)	Initiate: 25 mg Therapeutic: 50-200 mg	Best studied in pregnancy May have GI symptoms at initiation Activating - take in morning Inexpensive
Citalopram (Celexa)	Initiate: 10 mg Therapeutic: 20-40 mg	May have QTc prolongation Inexpensive
Escitalopram (Lexapro)	Initiate: 5 mg Therapeutic: 10-20 mg	May work more quickly Less activating - good in patients with anxiety
Fluoxetine (Prozac)	Initiate: 10 mg Therapeutic: 20-80 mg	Longest half-life - minimal withdrawal effect if misses a dose Activating - take in morning Inexpensive
Paroxetine (Paxil)	Initiate: 10 mg Therapeutic: 20-40 mg	Short half life - more withdrawal effects if miss a dose Potential increased risk of fetal heart defect May cause drowsiness and orthostatic hypotension

 

Follow up after recognition of mood disorder

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References

1. Pinette MG, Wax JR. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol. 2010;115(1):188-189; author reply 189.
2. ACOG Committee Opinion No. 757: Screening for Perinatal Depression. Obstet Gynecol. 2018;132(5):e208-e212.
3. ACOG Committee Opinion No. 757 Summary: Screening for Perinatal Depression. Obstet Gynecol. 2018;132(5):1314-1316.
4. Siu AL, Force USPST, Bibbins-Domingo K, et al. Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;315(4):380-387.
5. O'Connor E, Senger CA, Henninger M, Gaynes BN, Coppola E, Soulsby Weyrich M. Interventions to Prevent Perinatal Depression: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Rockville (MD)2019.
6. Yonkers KA, Wisner KL, Stewart DE, 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;31(5):403-413.
7. Kumar V, Sattar Y, Bseiso A, Khan S, Rutkofsky IH. The Effectiveness of Internet-Based Cognitive Behavioral Therapy in Treatment of Psychiatric Disorders. Cureus. 2017;9(8):e1626.
8. Wikman A, Axfors C, Iliadis SI, Cox J, Fransson E, Skalkidou A. Characteristics of women with different perinatal depression trajectories. J Neurosci Res. 2019.
9. Knapen J, Vancampfort D, Morien Y, Marchal Y. Exercise therapy improves both mental and physical health in patients with major depression. Disabil Rehabil. 2015;37(16):1490-1495.
10. Bulletins--Obstetrics ACoP. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists number 92, April 2008 (replaces practice bulletin number 87, November 2007). Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol. 2008;111(4):1001-1020.