Hani Raoul Khouzam1,2*
1Staff Psychiatrist, Mental Health and Psychiatry Services, USA
2Clinical Professor of Psychiatry and Medicine, USA
*Corresponding author: Hani Raoul Khouzam, Staff Psychiatrist, Mental Health and Psychiatry Services, Clinical Professor of Psychiatry and Medicine, California, USA
Submission: May 22, 2021;Published: June 18, 2021
ISSN: 2640-9666Volume4 Issue4
Depression is common during pregnancy. This review summarizes the risks associated with depression during pregnancy for the mothers and developing fetus, and the treatment of depression with antidepressants during pregnancy.
Keywords: Pregnancy; Depression; Antidepressants; Risks; Treatment
Abbreviations: SSRIs: Selective Serotonin Reuptake Inhibitors; SNRIs: Serotonin and Norepinephrine Reuptake Inhibitors; TCAs: Tricyclic Antidepressants
Depression is common during the childbearing years for women aged 15-44 years and it is estimated to affect 14.5% of pregnant women . Untreated maternal depression could have a detrimental effect on the pregnant women and their developing fetus. However there seem to be a decreased accuracy in diagnosing and treating depression during pregnancy . There is also a reluctance by pregnant women and clinicians to use antidepressants due to fears of their potential harmful effects on the pregnancy and the growing fetus . The accurate diagnosis of depression and its treatment with antidepressants while weighing on their potential risks and benefits would lead to an improved clinical outcome for pregnant mother, the growing fetus, and the newborn .
Depression can often be overlooked in pregnant women due to the similarity of its symptoms with the physiological disturbances associated with pregnancy such as sleep and appetite changes, diminished energy, and the marked decreased libido. Therefore, clinicians should evaluate the psychological rather than the physiological manifestation of depression such as a lack of interest in the pregnancy, ruminations of guilt, anhedonia, the presence of passive death wish, or the emergence of suicidal ideation . To accurately identify depression, clinicians caring for pregnant women can use the various screening tools that are specifically designed to recognize depression during pregnancy. These may include the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD,PHQ) , the Edinburgh Postnatal Depression Scale (EPDS) , the Beck Depression Inventory Scale (BDI-II)  and the Center for Epidemiologic Studies Depression Scale, Revised (CESDR) . The diagnostic and statistical manual of mental disorders criteria can also be used to confirm the diagnosis of depression regardless of pregnancy status .
The development of depression during pregnancy could be triggered by several psychosocial stressors such as exposure to trauma and violence, relationship conflicts, and inadequate social support systems. Poverty, food, housing and financial insecurities may further exacerbate these stressors. Single motherhood, unplanned or unexpected pregnancy, and having several infants and toddlers could also precipitate depression . Early age pregnancy especially during adolescence also increases of the incidence depression . A personal or family history of depressive illness could also predispose to depression during pregnancy . The discontinuation of antidepressant medications would frequently lead to the recurrence or the worsening of preexisting depression . Quality care for pregnant women would need to implement clinical guidelines that could identify and initiate psychosocial interventions to address and reverse these depression predisposing risk factors.
Maternal depression does not only affect the wellbeing of the pregnant mother but could have detrimental effects on the growing fetus and could lead to a worsening of pregnancy outcomes. Untreated maternal depression could have catastrophic effects such as suicide and, or infanticide [15,16]. Untreated depression during pregnancy has been associated with increase alcohol, tobacco and illicit substance use which would lead to negative consequences in the mother and the growing fetus . Malnutrition, poor adherence with prenatal care and failure to recognize or report the early signs of labor are also some of the sequelae of maternal depression resulting in poor obstetric, fetal, and neonatal outcomes . Increased levels of discomfort and multiple somatic complaints such as headache, nausea, stomach pain, shortness of breath, gastrointestinal problems, palpitations, dizziness, and sexual dysfunction, could also be manifestations of unrecognized depression often leading to unwarranted diagnostic procedures and medical interventions . Global functional impairment, pre-eclampsia, increased risk of postnatal depression and ultimately poor pregnancy outcomes have all been associated with untreated maternal depression .
Maternal depression has been associated with premature birth, low birth weight, and fetal growth restriction, and postnatal cognitive and emotional complications . Newborns of depressed mothers have been reported to have increased irritability, fewer facial expressions and could be at risk for developmental delay . Neonates whose mothers are depressed are more likely to have lower Apgar scores and a smaller head circumference . Infants of depressed mothers may experience dysregulation of their hypothalamic-pituitary-adrenal axis and higher admission rates to neonatal intensive care units . As they develop, these neonates may have more difficulty in engaging in social interactions, show less positive and more negative affect, and have worse developmental and emotional outcomes .
Antidepressant medications are generally considered safe
in the treatment of depression during pregnancy. They should
be seriously considered if the clinical assessment confirms the
presence of moderate to severe symptoms of depression, that are
affecting daily functioning and impairing the ability to care for self
and adherence with obstetric prenatal care. The reinitiating of the
same antidepressant that was discontinued due to the pregnancy
should be considered as a first option based on prior benefits that
were achieved by that medication. Available evidence suggests that
the Selective Serotonin Reuptake Inhibitors (SSRIs) are generally
considered an option during pregnancy, including fluoxetine
sertraline and citalopram [22,23]. Most studies show that SSRIs
are not associated with birth defects . Some concerns have
been raised regarding paroxetine being associated with a possible
increased risk of a fetal heart defect and pulmonary hypertension
thus discouraging its use during pregnancy .
The Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) such as venlafaxine and duloxetine could also be considered as another option during pregnancy the safety of duloxetine however has not been fully researched . Mirtazapine may be a viable option for use in pregnancy because unlike the SSRIs and SNRIs it is not associated with nausea, and it may be beneficial in some patients with hyperemesis gravidarum . It can cause weight gain which could predispose to possible obstetrical complications such as gestational diabetes, also its sedating properties may be cumbersome in pregnancy. It is still unclear if mirtazapine increases the risk of fetal malformations, and spontaneous abortion . Bupropion although not generally considered a first line treatment it may be a reasonable treatment option during pregnancy, particularly as an adjunctive agent that helps with smoking cessation .
Tricyclic Antidepressants (TCAs) such as nortriptyline and desipramine were widely utilized in pregnancy prior to the introduction of SSRIs and SNRIs. Some studies that have not been confirmed suggested that limb anomalies could occur with TCAs in pregnancy. Some infants exposed to TCAs exhibited acute effects that were similar to neonatal abstinence syndrome which could be manifested by tachypnea, tachycardia, cyanosis, irritability, hypertonia, and clonus. Current clinical guidelines do not recommend TCAs and as first line or second line treatment but could be used as an option during pregnancy for those who have not responded to the SSRIs ,SNRIs or other antidepressants.
Untreated maternal depression during pregnancy could have detrimental effects on the mother and the developing fetus and has been associated with premature birth, low birth weight, fetal growth restriction, and postnatal cognitive and emotional complications. Treating depression during pregnancy with antidepressants is considered generally safe and outweigh the risks associated with their potential side effects. High quality pregnancy care should include assessment tools to accurately recognize, diagnose and treat depression. Antidepressant medications are viable treatment options for moderate and severe depression for pregnant mothers who have not responded to implemented social and psychotherapeutic interventions. Fully informed treatment decision-making requires balancing the risks and benefits of proposed interventions against those of untreated depression.
Sincere gratitude and thankfulness to my wife Lynn and children, Andrew, Adam, Andrea and her husband Nic, and their daughter Abigail, my sisters Hoda and Héla, and my brother Hadi for their support and encouragement.
© 2021 Hani Raoul Khouzam. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and build upon your work non-commercially.