Perinatal depression: what you can do to reduce its long-term effects

Should you prescribe antidepressant medication?
Dr. Mittal believes that ObGyns should feel fairly comfortable prescribing antidepressant medication to patients who have mild or moderate depression, provided that the initiation of such medication is the patient’s informed choice.

Once severe disease (including bipolar disorder and a history of suicidality or psychosis or psychiatric hospitalization) has been ruled out and a history indicates that the patient has mild to moderate symptoms and has responded to treatment, an ObGyn is well qualified to treat perinatal depression, says Dr. Mittal.

Typically, SSRIs are the first-line treatment for perinatal depression and generally have similar amounts of data about their risk in pregnancy. Paroxetine (Paxil) is the exception, as we have more data about the risk for cardiac defects in neonates exposed to it in utero, Dr. Mittal says.

SSRIs generally are found in low amounts in breast milk, although sertraline (Zoloft) generally is found in the smallest quantity, making it the most commonly used SSRI in pregnancy. Sertraline is followed by citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac) in the respective amount of medication passed into breast milk.

The literature around the teratogenic risks of psychiatric medications is extremely diverse, she says. The “sum total” of the data suggests that SSRIs have relatively few teratogenic risks. “The overall story around SSRIs does not appear to suggest that they carry a risk of major malformations.”

Related Article: Antidepressants linked to pregnancy risks in infertility treatment (News for Your Practice, December 2012)

Dr. Mittal also recommends keeping in mind the possibility that psychotherapy alone is sometimes sufficient for a woman with mild to moderate depression.

“If she has a history of responding to psychotherapy alone and also has mild to moderate symptoms, I think a reasonable approach would be to try it again.”

“This is where preconception planning is especially useful,” she says. “If somebody with mild to moderate symptoms has never had a good trial of psychotherapy, the preconception period is a good time to determine whether it might be effective, to shape the optimal treatment plan.”

Two forms of psychotherapy have solid evidence of efficacy in perinatal depression:

• cognitive behavioral therapy (CBT) —an action-oriented approach that treats maladaptive thinking as the cause of ­pathologic behavior and “negative” ­emotions
• interpersonal psychotherapy (IPT)—a treatment in which the patient is educated about depression and its symptoms and her relation to the environment, especially social functioning. Unlike some other forms of therapy, IPT does not focus on underlying personality structures.

There are other forms of psychotherapy, but CBT and IPT have a large evidence base and are generally time-limited, rather than open-ended. They also are manualized and problem-focused, says Dr. Mittal.

How to prescribe an SSRI
SSRIs generally are initiated at a low dose and gradually titrated up (if necessary). A typical starting dose of sertraline, for example, would be 25 to 50 mg. The patient should be counseled about potential side effects, which include increased perspiration, somnolence or insomnia, nausea, diarrhea, headache, dizziness, and restlessness. These effects generally begin to subside the first week or two after initiation.

Sexual side effects such as reduced desire and difficulties with orgasm also may occur and generally do not diminish over time.

The patient also should be advised not to discontinue the SSRI abruptly, if at all possible, because of the risk that she might develop mild discontinuation syndrome. Although this syndrome is short-lived, self-limited, and non-life-threatening, it is uncomfortable. Symptoms include changes in mood or anxiety, shakiness, tremor, or gastrointestinal disturbance. If the patient elects to discontinue an SSRI, tapering over 4 to 7 days is preferable. However, in the event that the patient exhibits an adverse reaction or intolerance to antidepressant medication, immediate discontinuation may be appropriate, says Dr. Mittal.

After initiating SSRI therapy, follow-up in 2 weeks is appropriate, after which time oversight can be transferred to the patient’s primary care provider. In the United States, primary care physicians prescribe the bulk of SSRI medications.

It may take 6 to 8 weeks for the medication to begin to reduce depressive symptoms, although sleep and appetite sometimes improve within 1 or 2 weeks.

Avoid abrupt drug discontinuation in pregnancy
When asked to recommend one intervention that would have a big impact on reducing the burden of depression in pregnancy, Dr. Mittal zeroed in on the population of women who elect to discontinue antidepressant medication during pregnancy.

“I would suggest that ObGyns discourage these women against abrupt discontinuation,” she says. “There is a small body of literature that demonstrates that, in patients with significant illness—severe depression and bipolar disorder, ­certainly—abrupt discontinuation increases the likelihood of recurrence in the short period of time afterward. If medication is abruptly stopped when a woman discovers she’s pregnant, she’s likely to need to return to treatment during pregnancy because of recurrent symptoms. What happens in that case is that her pregnancy is exposed to both severe symptoms and the reinitiation of treatment, possibly including additional medications beyond the initial agent,” says Dr. Mittal.