Speaker highlights considerations for treating depression during and after pregnancy

Women with perinatal and postpartum depression likely benefit from the implementation of certain evidence-based strategies, according to a presenter at the NEI Max virtual conference.

These strategies are necessary, given the high prevalence rates of mood disorders during pregnancy, with 7.4%, 12.8% and 12% of women experiencing them in the first, second and third trimesters, respectively, and 20% of women experiencing postpartum depression, according to Andrew J. Cutler, MD, of Mount Auburn Hospital in Massachusetts.

“Untreated depression is associated with inadequate maternal weight gain, poor maternal self-care, substance use, preeclampsia, impaired fetal placental function, fetal distress, more C-sections, neonatal care unit admittance and postpartum depression,” Cutler said during a presentation. “As far as antidepressants, there's a question here: What about the risk for cardiac defects with antidepressants, autism, [postpartum hemorrhage], major cardiac malformations, postnatal adaptation syndrome. Then there's overlap in some of the concerns between the two: miscarriage, preterm birth, low birth weight, small for gestational age and long-term neurodevelopmental abnormalities, so this is really a difficult balancing act that we have to undergo here.”

Regarding clinical management during pregnancy, Cutler provided some insights for women currently taking medication:

• those who are psychiatrically stable and prefer to remain on medication may be able to if they consult with their clinician on the risks and benefits;

• those who want to discontinue medication can attempt tapering, depending on psychiatric history and current status;

• psychotherapy as a replacement or augmentation for medication may benefit those with current symptoms despite their medication or recurrent depression;

• those with severe depression should remain on medication; and

• alternative treatment and monitoring should be in place, preferably before discontinuation, for patients who refuse medication.

For women not currently taking medication, Cutler noted that psychotherapy may benefit those who prefer to avoid antidepressants. Among those who prefer taking medications, it is important to evaluate and discuss risk and benefits of treatment choices, which may include factors like gestation stage, symptoms, prior depression history and other health conditions.

Cutler pointed to recent findings that show the absolute risk for malformations related to selective serotonin reuptake inhibitor exposure in pregnancy is small. However, recent case-control studies showed inconsistent data regarding teratogenic risk for individual SSRIs. Further, there appears to be no evidence of increased risk for major malformations or cardiovascular malformations among children of pregnant women exposed to SSRIs. Cutler noted that two studies found no increased risk for autism related to SSRIs; however, one of these showed a small increased risk for preterm birth linked to first trimester exposure.

Study findings demonstrated that repetitive transcranial magnetic stimulation has a response rate of 41.4% to 70%, remission rate of 20.7% to 30% and partial response rate of 34.5% for perinatal depression. Exercise also appears to offer benefit during and after pregnancy, with an effect size of 0.41 (95% CI, 0.28-0.54).

Regarding prevention of postpartum depression, antidepressants have shown mixed results. A Cochrane review suggesting modest benefit in preventing perinatal depression, with insufficient data to suggest their use, but further results showed antidepressant use during the third trimester among euthymic women did not prevent postpartum depression. The Cochrane review concluded that the evidence is insufficient to say whether, and for whom, antidepressant or psychosocial are more effective for treating postpartum depression.

Cutler noted that sertraline, nortriptyline and escitalopram have shown efficacy for postpartum depression; however, the Agency for Healthcare Research and Quality concluded that data is insufficient regarding the efficacy of antidepressants for postpartum depression but that there is no evidence of harm to mothers or infants.

According to Cutler, other considerations before initiating an antidepressant for postpartum depression include the following:

• screen all patients diagnosed with postpartum depression for evidence of bipolar disorder;

• antidepressants should be used with caution among antidepressant-naive women who experience their first depressive episode during the postpartum period;

• women who have mixed depression should exercise caution while using antidepressants; and

• antidepressants should be tapered if postpartum psychosis develops, and treatment should be carried out with initiation or optimization of a mood stabilizer or atypical antipsychotic with mood stabilizing properties.

Brexanolone, a novel allopregnanolone formulation, may offer a faster-acting and more effective treatment for postpartum depression, according to Cutler.

“We always talk about risk-benefit with medications, but we have to remember there's a significant risk of inadequately treated or untreated depression, especially in the [perinatal] period,” Cutler said.