Treatment of Depression During Childbearing

One of the challenges that many physicians face is the treatment of depression during childbearing. Katherine L. Wisner, MD, MS of Women's Behavioral HealthCARE, WPIC, is a leading researcher on this topic. The following are questions she addresses in her NIMH-funded research (JAMA 1999; 282:1264-1269; Am J Psychiatry 2000; 157:1933-1940).

How can the risk-benefit decision-making process be structured?

Wisner's model focuses on the interaction between physician and patient. The physician's responsibility is to provide a diagnostic formulation and information about therapies that are tailored to the individual woman's clinical history. The patient and physician each contribute to the process, since the patient's assignment of her own values dictates her choice of treatment.

What information is available about the risks of pharmacotherapy?

Wisner and colleagues compiled data relating to specific domains of reproductive toxicity, which include: intrauterine fetal death, physical malformations, growth effects, neurobehavioral teratogenicity, and neonatal toxicity. Five prospective controlled investigations of the effects of antidepressant treatment during pregnancy are available. The drugs include the serotonin-selective reuptake inhibitors (SSRI's), tricyclic antidepressants, and venlafaxine. Exposure to these agents did not increase risk for intrauterine fetal death or major birth defects. Decreased birth weights of infants exposed to fluoxetine in the third trimester were identified in one study. The development of children whose mothers took tricyclics or fluoxetine during gestation did not differ from that of controls. Direct drug effects and withdrawal syndromes occurred in some neonates whose mothers were treated with antidepressants near term.

What are the risks of untreated depression?

Data on animal maternal stress and severe stress in humans is used to understand the possible effects of untreated depression on the fetus. In animals, maternal stress is associated with fetal hypoxia, low birth weight, smaller litter size, and miscarriage. Stress (without exposure to drugs) can cause behavioral teratogenicity. Not only are sleep and appetite disruption, which often accompany depression, not ideal for pregnancy, but parenting in the presence of depression is not optimal.

Dr. Wisner has designed a naturalistic study to examine the effects of antidepressant use during pregnancy. She will follow pregnant women from 20 weeks gestation through the first two years of their child's life to evaluate the presence of depression or antidepressants on pregnancy outcome and on the child's development.

What is known about the pharmacological management of postpartum depression?

Data suggest that women with postpartum depression may be particularly responsive to SSRI's. However, if the patient has previously had a response to a specific drug from any antidepressant class, that agent should be considered. Wisner and colleagues currently are comparing treatment with nortriptyline, a tricyclic, and sertraline, an SSRI, for postpartum depression. Wisner and her team have also received a grant to study the prevention of recurrent postpartum depression.

How does breastfeeding affect medication choice?

The risk to infants of lactating mothers who take antidepressants has been studied by monitoring mother and nursing infant serum levels. A table that outlines the implications for antidepressant use during breast-feeding is provided in Wisner's article (N Engl J Med, 2002; 347:194-199). In summary, the most data-based choices are sertraline (Zoloft) and paroxetine (Paxil).

This research will increase the sophistication of the risk-benefit decision-making process. For referrals call: (412) 246-5349.