Anxiety, depression persist despite antidepressant use in pregnancy, postpartum

Women who took antidepressant medication had persistent depressive and anxiety symptoms during pregnancy and postpartum, with some women experiencing increased anxiety symptoms, data showed.

“Sustaining remission through the use of medication of perinatal major depressive disorder (MDD) is essential for achieving optimal maternal and offspring health,” Gabrielle A. Mesches, MS, of the department of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine, and colleagues wrote in Psychiatric Research & Clinical Practice. “Given the high comorbidity, clinical guidelines recommend screening for anxiety disorders in women with perinatal MDD, [and] the individual symptom trajectories of anxiety and depression vary across pregnancy to postpartum.”

Treatment for MDD typically includes selective serotonin reuptake inhibitors (SSRIs), though existing studies have not provided concrete evidence on the efficacy of SSRIs in pregnancy, the researchers wrote.

“Our goal is to analyze the depressive and anxiety symptom trajectories across pregnancy and after birth in women who did not have syndromal MDD at entry and who were maintained on one of the four commonly prescribed SSRI antidepressants that have equivalent effectiveness,” they said.

Enrollment and assessment

Mesches and colleagues enrolled 88 pregnant women (89% white) by 18 weeks’ gestation who had a diagnosis of MDD and were currently taking sertraline (n = 47), fluoxetine (n = 10), citalopram (n = 9) or escitalopram (n =22). Participants continued using their initial SSRI for the entire study period.

Researchers conducted interviews at baseline and every 4 weeks through delivery, and continued follow-up with 77 women at 6 and 14 weeks postpartum. To assess MDD, anxiety and physical health at each interview, they used the 10-item Edinburgh Postnatal Depression Scale (EPDS), the 16-item Quick Inventory of Depressive Symptoms (QIDS), the 7-item Generalized Anxiety Disorder Scale (GAD-7) and the 10-item Patient-Reported Outcomes Measurement Information System Global Health (PROMIS-GH) T-scores. Scores were used to identify and group participants with similar symptom progression.

Depression, anxiety continue

Trajectories of EPDS scores — categorized as minimal (18%), mild (50%) and subthreshold (32%) by increasing severity — remained relatively stable throughout pregnancy and postpartum, with the exception of subthreshold levels, which started high, decreased by 9 months’ gestation and increased postpartum. SSRI dose increase was not significantly associated with any depression trajectory, the researchers said.

QIDS scores confirmed the three EPDS trajectories, although there was a different progression of depressive symptoms. However, this difference was not significant.

Of note, the presence of an eating disorder was predictive of QIDS group membership, with 4% of the minimal group, 26% of the mild group and 11% of the subthreshold group reporting an eating disorder.

Regarding anxiety, the GAD-7 scores followed four trajectories — asymptomatic (7%); minimal (53%); breakthrough, or increasing symptoms (18%); and mild (23%). In general, the anxiety trajectories were positively associated with the EPDS trajectory groups, according to the researchers. The asymptomatic and minimal trajectories identified through GAD-7 scores remained stable through pregnancy and after birth. The breakthrough trajectory revealed a trend of increasing anxiety symptoms over the duration of study, while there was a decrease in symptoms for the mild trajectory.

“Our findings demonstrate that the treatment goal to achieve full resolution of maternal depression symptoms remains a clinical challenge,” Mesches and colleagues said. “Despite maintenance treatment, pregnant women with MDD frequently had residual symptoms at enrollment and throughout pregnancy and postpartum.”

Because the study consisted mainly of white women and only evaluated SSRIs, the researchers emphasized the need for more research.

“Additional intervention research is needed to enhance the effectiveness of maintenance medication, especially for women in the highest scoring QIDS and EPDS trajectories, respectively,” they said.