Mamas on Bedrest: Psychotherapy or SSRI’s for Prenatal Depression

October 3rd, 2012

More and more attention is being given to perinatal mood disorders, and finally to prenatal depression. Until very recently, many clinicians didn’t believe that expectant mamas got depressed! The consensus seemed to be,

“She’s pregnant, right? Of course she’s happy!”

What research data is now showing is that regardless of whether the pregnancy is planned or not, or regardless of whether the mother wants the baby or not,  many women-across all ages, races and backgrounds-experience prenatal depression.

In September 2012, 2 new articles were published discussing treatment of prenatal depression. Alison K Shea, MD, PhD and colleagues at the University of Toronto, in Ontario, Canada examined the effectiveness and risk of Selective Seratonin Reuptake Inhibitors (SSRI’s like Paxil, Prozac, etc..) as treatment for depression in pregnant women. Their study looked at key factors that influence maternal and fetal drug exposure during pregnancy and the potential but still unknown long-term developmental consequences of prenatal exposure to antidepressants.

Sherryl H Goodman, PhD at Emory University in Atlanta, Georgia and and  Sona Dimidjian, PhD at the University of Colorado in Boulder examined and identified how psychosocial treatment of depression during pregnancy may be enhanced by taking a developmental psychopathology perspective.  Dr. Goodman and Dr. Dimidjian point out that psychopathology occurs on a continuum.

“The developmental psychopathology emphasis on disorders occurring on a continuum of severity is highly relevant to intervention considerations for antenatal depression,” they write, “especially when considering pharmacological as opposed to nonpharmacological treatment for more severe vs less severe depression.”

This is a really interesting contrast. The Canadian researchers are proposing that we focus more on the action of drugs and make sure that risks and side effects are minimized while also making sure that the drugs are metabolized safely and working in safe and effective doses.  They are not considering any sort of psychotherapy at all-at least not stated in their publications.

The American researchers are at the polar opposite end of the pendulum stating that while medication has a place in treating depression, in pregnant women, looking at how psychological disorders manifest-at different times and in different intensities in a person’s life depending on circumstances-one may be able to pre-emptively abort depressive episodes or at the very least minimize their severity. In pregnancy especially, women with prior depression are at increased risk of developing perinatal depression, so identifying those women with a history of depression early and taking a proactive approach to their mental health (i.e. taking steps to avoid developing a full blown depression in the first place) may in fact be a more effective treatment in the long run. (It certainly has fewer systemic side effects!)

What we do know is that depression is no good for mamas or babies.

I am more and more encouraged to see research being focused on perinatal mood disorders. Depression in mamas, whether pregnant, newly post partum or well into motherhood is a known risk factor for maternal morbidity and mortality, but also for impaired development in the fetuses, infants and children. When a pregnant mama is not feeling well emotionally, she doesn’t take optimum care of herself and hence doesn’t take optimum care of her baby. In these cases, we can see intrauterine growth retardation or failure to thrive. In extreme cases, we may see fetal demise. Depressed new mamas my avoid their babies and as a result feeding is impaired, the baby may not grow as expected for age and/or may experience behavioral/developmental. Children of depressed mamas often exhibit behavioral problems, learning difficulties and in extreme cases abuse. Clearly, treating depression is essential for the health and well being of mamas and their children.

And while I can appreciate the need to be aware of the dosing and pharmacologic activity of antidepressants in pregnant women, I have to agree with the researchers from Emory and U. Colorado; failing to look at psychosocial issues such as socioeconomic status, marital relationship and social support when evaluating a mama for depression is overlooking the potential causes of depression. If a pregnant woman is in a difficult marriage, simply giving her an antidepressant without taking into consideration the issues of her marriage and getting appropriate counseling is not really adequately treating her depression. If a pregnant mama is not safe at home or doesn’t have a home, an antidepressant is woefully inadequate at addressing her needs. Only with careful consideration of a pregnant mama’s entire history-including her psychosocial history-can adequate treatment for depression be rendered. In many cases, both medication and psychotherapy will be needed.

When it comes to depression in and around pregnancy, I am a firm believer that all options need to be presented and utilized for treatment. Because of a pregnant mama’s physical condition and the risk of toxicity to the baby,  medication may not be the best option. For other pregnant mamas, psychotherapy alone may prove inadequate. But if we continue to explore and make available all treatment options, I think we’ll be well on our way to effectively treating depression in mamas at all stages of their reproductive lives.

Resources

Managing Depression in Pregnancy: The Debate Continues. Medscape OB/GYN and Women’s Health

“Fetal Serotonin Reuptake Inhibitor Antidepressant Exposure: Maternal and Fetal Factors”  Alison K Shea, MD, PhD; Tim F Oberlander, MD, FRCPC; Dan Rurak, PhD.  Canadian Journal of Psychiatry. 2012;57(9):523–529.

“The Developmental Psychopathology of Perinatal Depression: Implications for Psychosocial Treatment Development and Delivery in Pregnancy” Sherryl H Goodman, PhD; Sona Dimidjian, PhD.  Canadian Journal of Psychiatry. 2012;57(9):530–536.

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