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Harvard Commentaries
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Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Minding Your Mind Minding Your Mind
 

Treating Depression During Pregnancy


June 24, 2013

By Michael Craig Miller M.D.

Harvard Medical School

Although pregnancy is a joyful time for many women, many others struggle with depression and other mood disorders.

The limited data we have suggest that 7.5% of women who become pregnant develop major depression. Another 7% have less severe forms of depression before giving birth.

Consensus is growing that depression during pregnancy should be treated, because:

  • Untreated depression during pregnancy increases the likelihood that a woman will have postpartum depression.
  • Newborns of depressed mothers are more likely to be lethargic, irritable and have lower birth weights.

Medication is one option for treating prenatal depression. In 2003, 13% of pregnant women used antidepressants at some point during pregnancy. But many women prefer not to take antidepressants during pregnancy. They are concerned about exposing the developing fetus to any type of drug.

In general, psychotherapy is recommended for pregnant women with mild to moderate depression.

Medication is recommended for patients with:

  • Severe depression
  • Psychosis
  • Bipolar disorder
  • A history of suicide attempts
  • A co-occurring psychiatric disorder that requires drug treatment

Unfortunately, there is scant research on alternatives to medication — whether psychotherapy or other modalities. So choosing the best treatment depends on the doctor's experience and the patient's preference.

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Medications for Prenatal Depression

Selective serotonin reuptake inhibitors (SSRIs) are the drugs most often used to treat depression during pregnancy.

  • SSRIs can be taken during the first trimester of pregnancy without significantly increasing the risk of fetal heart defects or other major birth defects. (Preliminary research suggested that paroxetine [Paxil] might be the exception to this general rule, but a larger study concluded that this drug did not increase risk of congenital heart defects.)
  • SSRI's taken late in pregnancy may lead to short-term withdrawal symptoms in as many as 25% of newborns after delivery. Typical symptoms include tremor, restlessness, mild respiratory problems and a weak cry. These problems usually resolve in one to four days.
  • It remains unclear if an SSRI taken later in pregnancy increases the risk of persistent pulmonary hypertension of the newborn, a serious but rare respiratory problem.

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Psychotherapy Options

The best-studied type of psychotherapy for prenatal depression is interpersonal psychotherapy. This is a brief, highly-structured approach that helps a patient improve her mood by focusing on interactions with other people.

Researchers at Columbia University have adapted interpersonal therapy to help pregnant women to deal with transitions to a new (or expanded) role as a parent, or deal with medical complications of pregnancy. The research showed that women getting interpersonal therapy improved faster and significantly more than those who received parent education.

Cognitive behavioral therapy is a well-established treatment for depression. It helps you identify and change self-defeating thoughts and behaviors.

Psychodynamic therapy helps you develop insight into internal psychological conflicts. As a result, you may be able to manage those conflicts better.

Supportive psychotherapy relies on a variety of techniques to shore up the healthy and adaptive skills you already have.

Any of these can be effective treatments for depression symptoms. Because there is little or no research on which psychotherapy is best in every case, it's reasonable to choose the type of psychotherapy you prefer.

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Acupuncture and Massage

Acupuncture involves the insertion of tiny needles into specific areas of the body to relieve symptoms. The practice, which began in Asia, is premised on a philosophy that illness results from an imbalance in "life energy" (known as qi, pronounced CHEE). The theory is that stimulating various "acupoints" can restore balance.

There is little evidence proving that acupuncture is effective for pregnant women with depression. It is a challenge to design truly random, blind studies, as the clinician and patient usually know whether or not the acupuncture is the treatment.

The same is true for massage. The research available does seem to indicate that both acupuncture and massage may ease the aches and pains that occur in pregnancy and in turn may improve mood and anxiety.

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Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is an option for pregnant women with severe depression who have not responded to antidepressant drugs. It is an especially effective treatment for those at risk of suicide and those suffering from psychotic depression. Some women may also prefer ECT to medication during pregnancy because it is a safer treatment, in some ways.

ECT is safe as long as both the pregnant woman and the fetus are carefully monitored. Prior to ECT, if the delivery date is near, the doctor may perform a pelvic exam to check whether the cervix has begun to open or soften in preparation for childbirth. The doctor may use a fetal heart monitor during the procedure. In rare cases, ECT may trigger uterine contractions, but the procedure does not increase risk of premature labor or miscarriage.

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Bright Light Therapy

Bright light therapy using a light box helps adjust the biological clock that affects our sleep and mood. This therapy is often recommended for people with seasonal mood disorders. The dose of light is measured in "lux." (A sunny day is 50,000 lux, while indoor light is about 100 lux.)

Again, there is limited research on light therapy in pregnant women, so it cannot be recommended as a standard treatment. It is, however, worth a try, especially for a woman who has a seasonal component to her depression.

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Finding the Best Approach

All medical decisions are personal, but decisions about treatment during pregnancy are more than personal. They extend to the next generation. Fortunately, most of the treatments described here are relatively safe.

The first task is to choose between psychotherapy and medication. You can also consider combining the two. Then you can add one of the other approaches as you see fit, for example, massage or light therapy.

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Michael Craig Miller, M.D, is Senior Editor of Mental Health Publishing at Harvard Health Publications. He is an assistant professor of psychiatry at Harvard Medical School. Dr. Miller is in clinical practice at Beth Israel Deaconess Medical Center, where he has been on staff for more than 25 years.

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