Last week’s e-Weekly discussed the different depressive syndromes as related to pregnancy. This e-Weekly will go into detail about treatment for depression for a patient who is in the antepartum or postpartum period. The first step is to determine the level of impairment of the symptoms. Baby blues resolves on its own with support and psycho-education and does not require further treatment. For patients who are mildly impacted by their depressive symptoms, individual or group therapy is the first line treatment recommendation. Light therapy can also be considered.
Medication can be an important treatment for antepartum and postpartum depression (PPD), if the symptoms are moderate-severe and/or not responding to non-medication approaches. The selective serotonin reuptake inhibitors (SSRIs) are the first line agents, in particular sertraline because of its relatively short half-life and availability of low doses (can be dosed as low as 12.5 mg per day). Paroxetine is pregnancy category D because of there is evidence that it increases the risk of birth defects, including rare cardiac and CNS effects. While these birth defects are very serious, it is important to keep in mind that they are very rare at baseline and that the increase in absolute risk from SSRI use is very minimal and depends on the SSRI being considered. There is also a possible connection between SSRI use in the third trimester of pregnancy and development of persistent pulmonary hypertension of the newborn in infants. There have been reports of newborns experiencing temporary discontinuation symptoms at birth, including jitteriness and irritability when a woman is treated with antidepressants during pregnancy. Other antidepressants, like the SNRIs and tricyclic antidepressants, are not typically recommended during pregnancy.
The SSRIs are also the first line medication treatment in the postpartum period for patients for whom medication might be indicated. Of the SSRIs, sertraline and paroxetine are the least detectable in breast milk, because of their relatively short half-lives. Several case reports note an association between fluoxetine and citalopram use in lactating women and infant irritability, poor sleep, poor feeding, crying, and restlessness. This might be related to these medications’ relatively longer half-life. Other case reports have not noted any adverse effects in infants of mothers taking fluoxetine and citalopram. If one is considering treating PPD with a medication, sertraline is a good first line agent because of its relatively shorter half-life and ability to dose in smaller doses, as low as 12.5 mg per day. The peak level of sertraline in breast milk is between 7-10 hours after taking the medication, which can be kept in mind to determine the optimal time for the patient to take the medication. If a woman is already on an antidepressant like fluoxetine with a good response, it is okay to continue with the medication and monitor closely for side effects in the mother and infant.
The important take home point for treating depression related to pregnancy is to first consider a non-medication treatment. If it is determined medication is needed, it is important to have a careful discussion about the risks and benefits and to try to use the smallest possible dose for the shortest length of time, with sertraline being a good first choice for both the antepartum and postpartum period.