Katherine L. Wisner, MD, MS
Dr Wisner is professor of psychiatry, obstetrics and gynecology and reproductive sciences, epidemiology, and women’s studies, Women’s Behavioral HealthCARE, at the Western Psychiatric Institute and Clinic of the University of Pittsburgh Medical Center; and associate investigator at the Magee-Womens Research Institute in Pittsburgh. She reports that she has received a donation of placebo transdermal patches from Novagyne for an NIMH-funded study.
Major depressive disorder (MDD) is common during childbearing. Depression that interferes with function develops in an estimated 14.5% of pregnant women.1 In a recent population-based study, Munk-Olsen and colleagues2 determined the prevalence of psychiatric disorders relative to childbearing. The overall risk for any psychiatric episode after delivery was elevated for women during the first 3 postpartum months. However, the increased risk specifically for major depression remained elevated for 5 months after birth. These statistics are troubling in that only 13.8% of pregnant women who screen positive for depression actually receive treatment.3
MDD is associated with substantial perinatal risk directly related to the physiological sequelae of maternal psychiatric illness. Hypothalamic-pituitary-adrenal axis hyperactivity may directly affect fetal growth and increase corticotropin-releasing hormone release from the placenta, which affects the timing and onset of delivery.4 Furthermore, women with depression have a 2.5-fold increased risk for preeclampsia during pregnancy.5
Maternal health behaviors associated with MDD (such as cigarette and substance use, poor adherence to obstetrical care, deficient nutritional intake, and social isolation) increase the risk for poor pregnancy outcome.6,7 Although rare, maternal suicide attempts (which occur in 0.4 per 1000 pregnancies) are another potential complication of MDD.8 Fetal exposure to MDD has an adverse impact on later child development that is independent from the child’s exposure to maternal postpartum depression.9
These observations support consideration of maternal MDD as a potent risk factor to the mother, fetus, and family. Identification and treatment of depression during pregnancy deserves to be a public health priority to reduce the health burden for women, families, and communities.10
In this article, I discuss general principles of treatment of MDD during pregnancy, evidence-based treatments for outpatient care (psychotherapy, SSRI pharmacotherapy, electro-convulsive therapy [ECT], and morning bright light treatment), and the proposed FDA classification system for drug use during pregnancy…