Current recommendations address perinatal depression screening, diagnosis, treatment

Key takeaways:

• Guidelines recommend several perinatal depression screenings in pregnancy and postpartum.
• Treatment options are psychotherapy and pharmacotherapy.
• New programs will help clinicians care for perinatal depression.

Current perinatal depression recommendations aim to help with early screening, diagnosis and treatment and to prevent maternal mortality.

“Perinatal mental health conditions are the leading cause of overall and preventable maternal mortality and include a wide array of mental health conditions, including anxiety, depression and substance use disorders,” Tiffany A. Moore Simas, MD, MPH, MEd, chair and professor of obstetrics and gynecology at the University of Massachusetts Chan Medical School and Memorial Health, and colleagues wrote. “Perinatal depression specifically affects one in seven perinatal individuals.”

Screening and diagnosis

ACOG released new guidelines in June that recommend screening for depression at least twice in pregnancy and during the postpartum period. Depression screening is also recommended at pediatric well-infant/child visits and well-women visits. To screen for perinatal depression, the most widely used instruments are the Patient Health Questionnaire and the Edinburgh Postnatal Depression Screen, which are all self-administered, easy to score with scores of 10 or higher considered positive, include questions on self-harm and are validated in multiple languages.

For a perinatal depression diagnosis, current recommendations suggest depression diagnoses requiring at least five symptoms present within the same 2-week period and at least one symptom being depressed mood or loss of interest or pleasure.

Recommendations note that clinicians should inquire about symptom type, frequency, severity and duration and how they impact daily functioning. Before making a perinatal depression diagnosis, recommendations also state that additional history and/or laboratory evaluation may be required to assess other potential etiologies.

In addition, clinicians should screen for bipolar disorder before initiating treatment because up to 20% of women screening positive for perinatal depression may have bipolar disorder. This is treated with mood stabilizers instead of antidepressants because treating bipolar disorder with antidepressants can cause mania, mixed states, rapid-cycling or psychosis, which can increase risks for suicide and infanticide.

Perinatal depression treatment

Current treatments for women with perinatal depression include psychotherapy, which is the first-line treatment for mild depression, and pharmacotherapy. Researchers noted hesitance with pharmacotherapy initiation during pregnancy or when breastfeeding due to concerns about effects on the fetus or infant. However, not treating perinatal depression properly can increase the risks for preterm birth, low birth weight, preeclampsia, neurodevelopmental effects, issues with social support systems, suicide and more, the researchers noted.

The most commonly prescribed medications for perinatal depression are selective serotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrine reuptake inhibitors (SNRIs). These methods are highly effective, but symptom improvement can take 4 to 6 weeks, the researchers noted.

“SSRIs in particular are some of the best studied medications during pregnancy and are considered reasonable first-line pharmacotherapy during all trimesters and lactation,” the researchers wrote.

The most common adverse effects with SSRIs or SNRIs include nausea, dry mouth, insomnia, diarrhea, headache, dizziness, agitation, sexual dysfunction and drowsiness.

In 2019, brexanolone (Zulresso, Sage Therapeutics), a synthetic neuroactive steroid, was approved to treat moderate to severe perinatal depression in the third trimester or within 4 weeks postpartum. Brexanolone is administered through 60-hour IV infusion with inpatient admission and costs more than $34,000 per patient. In addition, it is not recommended to breastfeed during infusion or for the 4 days after infusion.

In August, zuranolone (Zurzuvae, Sage Therapeutics), an oral synthetic allopregnanolone, was approved by the FDA to treat perinatal depression. Zuranolone is administered for 14 days as a nightly oral pill taken after consuming a fatty meal and can be used alone or in addition to other antidepressants like SSRIs/SNRIs. Due to a lack of data, recommendations suggest avoiding pregnancy and using shared decision-making for lactation decisions when using zuranolone. Data on zuranolone access, follow-up needs, long-term remission and insurance coverage are not yet available, the researchers noted.

According to the researchers, Perinatal Psychiatry Access Programs are a new and widely available model designed to increase the capacity of clinicians caring for preconception, pregnant, postpartum and lactating women to address perinatal mental health conditions and substance use disorder. These programs work with clinicians through:

• training and toolkits;
• clinician-to-clinician telephone psychiatric consultation and face-to-face patient consultation;
• linkages to community-based mental health recourses; and
• technical assistance to facilitate practices integrating mental health care into their workflow.

Currently, there are 22 U.S. state programs and two national programs with additional programs anticipated with support from the Consolidated Appropriations Act of 2023 and the Into the Light for Maternal Mental Health and Substance Use Disorders Act.

“Collectively, the effectiveness and impact of perinatal mental health treatments are directly proportional to perinatal individuals’ ability to access them,” the researchers wrote. “State-based and national access programs are available to help clinicians address perinatal mental health and increase access to care.”