Management of Depression in Pregnancy

Initial Assessment and Non-Pharmacological Management

• The American Academy of Pediatrics recommends screening all pregnant women for depression using validated tools such as the Patient Health Questionnaire, Hospital Anxiety and Depression Scale, or Edinburgh Postnatal Depression Scale 1
• For mild depression with recent onset, the American College of Obstetricians and Gynecologists suggests beginning with monitoring and encouraging exercise and social support before initiating pharmacological treatment 2
• Evidence-based treatment should be offered for mild depression that doesn't improve within two weeks or moderate-to-severe depression, according to the Journal of Child Psychology and Psychiatry and Allied Disciplines 2
• The Journal of Child Psychology and Psychiatry and Allied Disciplines states that evidence-based psychotherapies, such as cognitive therapy, are roughly equally effective as antidepressants for treating depression and should be considered first-line treatment for mild-to-moderate depression 2

Pharmacological Management

• The American College of Obstetricians and Gynecologists recommends considering antidepressants for women with moderate-to-severe depression 2, 1
• Antidepressants may be appropriate for women with a history of severe suicide attempts or severe depression who previously responded well to medication, according to the Journal of Child Psychology and Psychiatry and Allied Disciplines 2
• The Journal of Child Psychology and Psychiatry and Allied Disciplines suggests considering antidepressants for women who have previously relapsed when discontinuing antidepressant treatment 2, 1
• Women who have tried psychotherapy without adequate symptom reduction should be considered for antidepressants, according to the Journal of Child Psychology and Psychiatry and Allied Disciplines 2
• The American Academy of Family Physicians states that SSRIs are the most commonly prescribed antidepressants for pregnant women 3
• Sertraline and paroxetine transfer to breast milk in lower concentrations than other antidepressants, making them preferred options during breastfeeding, according to the American Academy of Family Physicians 3, 4

Risks and Benefits Assessment

• Depression during pregnancy is associated with premature birth and decreased initiation of breastfeeding, according to the American Academy of Family Physicians 3
• Antidepressant use during pregnancy may increase the risk of preterm delivery compared with untreated women who have depression, according to the American Academy of Family Physicians 3
• The FDA revised its 2006 advisory on SSRI use after the 20th week of gestation in 2011, stating that conflicting findings make it unclear whether SSRIs during pregnancy cause persistent pulmonary hypertension of the newborn (PPHN), as reported by the American Academy of Family Physicians 3, 1
• A meta-analysis found a link between late pregnancy exposure to SSRIs and PPHN, with a number needed to harm of 286 to 351, according to the American Academy of Family Physicians 3
• Recent evidence provides reassurance that antidepressant use during pregnancy is unlikely to substantially increase the risk of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD), according to the Journal of Child Psychology and Psychiatry and Allied Disciplines 5, 6, 1
• Studies have suggested associations between antidepressant use in pregnancy and lower Apgar scores, ADHD, and speech delay, although high-quality evidence is lacking, as reported by the American Academy of Family Physicians 3

Treatment of Depression in Pregnancy

Risks and Benefits of SSRI Treatment

• Neonatal adaptation syndrome occurs in approximately 30% of third-trimester exposures to SSRIs, with symptoms including crying, irritability, tremors, poor feeding, hypertonia, tachypnea, sleep disturbance, and hypoglycemia, but is typically self-limiting, resolving within 1-4 weeks, as reported by the Pediatrics journal 7
• The patient should be informed that neonatal adaptation symptoms, while concerning, are typically self-limiting and resolve within 1-4 weeks, according to the Pediatrics journal 7

Sertraline Use in Pregnancy

Benefits and Risks

• The American Academy of Family Physicians suggests that sertraline is a preferred choice for breastfeeding mothers due to its low transfer to breast milk 8
• The American Academy of Family Physicians notes that sertraline is one of the most commonly prescribed antidepressants for pregnant women, with a relatively steady concentration during pregnancy 8
• A large population-based cohort study found no link between first-trimester antidepressant use and cardiac malformations, according to the American Academy of Family Physicians 8
• The FDA reclassified paroxetine (not sertraline) as pregnancy category D in 2005 for cardiac concerns, as reported by the American Academy of Family Physicians 8
• The American Academy of Family Physicians states that the FDA revised its 2006 advisory in 2011, stating that conflicting findings make it unclear whether SSRIs cause Persistent Pulmonary Hypertension of the Newborn (PPHN) 8
• A meta-analysis found a link between late pregnancy SSRI exposure and PPHN with a number needed to harm of 286-351, according to the American Academy of Family Physicians 8
• The American Academy of Family Physicians notes that antidepressant use during pregnancy may increase risk of preterm delivery compared to untreated women with depression 8
• However, the American Academy of Family Physicians also states that untreated depression itself is associated with premature birth and decreased breastfeeding initiation 8
• The American Academy of Family Physicians suggests that sertraline can be safely continued during breastfeeding 8