Best Drugs for Depression during Pregnancy and Postpartum…

Drug Choices during Pregnancy and Breastfeeding

During pregnancy, symptoms of depression are common and can be difficult to disentangle from symptoms frequently reported during pregnancy (fatigue, sleeplessness, appetite changes). Symptoms are highly predictive of subsequent postpartum depression. The decision to initiate or continue treatment during pregnancy should be based on a risk-benefit analysis that considers both the fetus and mother. Keep in mind that untreated maternal depression is associated with untoward effects for the fetus/neonate, the mother and her partner. So, lots to consider.

Management of depression while pregnant

If symptoms are mild or if criteria for a mild depressive episode are met, psychotherapy (such as IPT which is short for Interpersonal therapy, is a short-term, focused treatment for depression and CBT Cognitive behavioral therapy) is the 1^st treatment option. For moderate to severe episodes, antidepressant medication should be considered, especially in women with a past history of depression. Evidence suggests that these medications are not major teratogens (cancer causing), although a statistical association may exist between cardiovascular malformations, such as ventricular or atrial septal defects, and fetal exposure to antidepressants, specifically paroxetine. Despite these statistically significant results, the clinical significance of this association has been questioned; paroxetine, however, remains a less preferred agent of the SSRIs. The association between fluoxetine and major malformations remains more controversial. Adverse delivery outcomes (e.g., preterm birth, among others) have also been statistically associated with antenatal antidepressant use, although the clinical relevance is not certain. Third-trimester pregnancy SSRI (Selective serotonin reuptake inhibitors) exposure may be associated with an increased risk of persistent pulmonary hypertension in the newborn. Examples of SSRIs include:

• Citalopram (Celexa®)
• Escitalopram (Lexapro®- Cipralex®)
• Fluoxetine (Prozac®)
• Paroxetine (Paxil®, Pexeva) least preferred agent during pregnancy.
• Sertraline (Zoloft®)
• Vilazodone (Viibryd®)

Other potential postbirth adverse effects include typically transient neonatal withdrawal or discontinuation symptoms (e.g., tremors, shaking, irritability, increased muscle tone, sleeping disturbances, respiratory distress); more severe symptoms have also been reported. Although a dose-dependent relationship has not been elucidated, if antidepressants are prescribed during pregnancy, use the lowest effective dose. There is a possibility that the newborn may experience transient withdrawal symptoms and may require monitoring by a pediatrician. As this area is actively evolving, please consult “Drug Use during Pregnancy” or other drug information services for the most up-to-date information.

Postpartum Depression

Rates of postpartum depression vary according to the severity of the episode. Postpartum “blues” affect up to 80% of women. Postpartum major depression occurs in up to 16% of new mothers in civilized worlds and postpartum psychosis in ≤0.1%.

The blues are not a disorder per se, given that they are so common and symptoms are self-limiting, requiring only monitoring and supportive care. However, women with postpartum blues are at risk of developing a depressive episode.

Management of Post Partum

Psychotherapy, preferably IPT or CBT, should be considered first for the treatment of postpartum depression, particularly if the mother is breastfeeding. When the illness is more severe, psychotherapy may be inadequate or inappropriate, in which case antidepressant treatment should be initiated. For breastfeeding patients, the 2016 CANMAT guidelines on MDD recommend consideration of sertraline, escitalopram or citalopram.

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GENERAL Antidepressants Therapeutic Tips for prescribers

• Prescribers should choose 1 or 2 agents from several antidepressant classes and use them consistently to acquire expertise in the use of those medications.
• Provide key psychoeducational messages ) with the initial prescription. Reinforce and add to this during regular follow-up visits.
• Reinforce the importance of maintenance therapy beyond the acute phase.
• There is a limited role for therapeutic drug-level monitoring as there is a poor correlation between serum levels of SSRI or SNRI antidepressants and clinical response or side effects. Similarly, there is only a limited benefit in performing pharmacogenetic testing for cytochrome P450 enzyme polymorphisms. Pharmacogenetic testing is, however, warranted in cases such as a failure to respond to high doses of several antidepressants (which may suggest that the patient is an ultra-rapid metabolizer) or repeated inability to tolerate low doses of several agents (which may suggest a poor metabolizer status).
• Provide patients with reliable information on drug interactions and dietary restrictions.
• In nonresponders, review alcohol and drug abuse history, assess medication adherence and confirm diagnosis.
• Refer for psychiatric consultation if the patient has psychotic symptoms or acute suicidal ideation, or after failure of 3 treatment trials.
• When discontinuing antidepressants, taper slowly over 4–6 weeks. This is particularly important for paroxetine and venlafaxine.

References available and provided to you upon request.