Engaging

Women are often reluctant to admit how they are feeling and, in
some cases, particularly to doctors, who they fear will give them
an antidepressant. Women who present frequently to their child
health nurse or general practitioner, and do not appear to be
their usual selves should be asked again and again about their
own health. Talking about normal 'stress' rather than depression,
and engineering a view that to get help in fact makes them a
good mother, might help break down the barriers over time.

Management

Many women with postnatal depression can be managed, at
least initially, without medication. Unless the woman has very
significant or long-standing symptoms, it is worth starting with
psychosocial management. Antidepressants can be mentioned
as one possibility if things do not improve. Although trials have
been limited in postnatal depression, evidence suggests that
antidepressants do have a role in treatment.2
The key to deciding about medication lies largely in diagnosis
– is this an adjustment disorder or a major depression?
Management must also take into account the woman's
particular circumstances (see Box 2). The decision to prescribe
is made in conjunction with the woman, and ideally her partner.
Some partners are not supportive and may have strong views
about the effect of drugs when the woman is pregnant or
breastfeeding.

Psychosocial interventions

While postpartum psychosis (a probable variant of bipolar
disorders) may have a clear biological aetiology, perinatal
depression appears to begin at least as a stress response, in
someone predisposed through personality or genetics. While
the end result may be biological changes that will respond to
medication, unless the stress is dealt with, recovery is likely
to be delayed or prevented. In many cases, stress reduces as
the baby ages, becomes more predictable, and life develops
a routine. Women can be helped as they adapt to their new
lifestyle. They need an opportunity to talk about their feelings
and experiences. Although there are common themes, they will
vary among women. For some a traumatic birth may be
an issue, for others not being 'in control' or loss of lifestyle
may be crucial to their feelings.
Therapeutic groups can be effective3, but new mother groups
can be counterproductive with depressed women feeling they
are failures compared to the 'normal' mothers around them.
A specific group can target the common anxieties of these
depressed mothers, such as needing to be perfect and always
there for their child, as well as focusing on the relationship with
their infant. Many groups also include the partner for at least
some sessions as the advent of parenthood and coping with a
depressed woman can have a significant effect on the partner's
mental health, as well as on the relationship.
It is important to look at the available supports and try to
enhance these. Childcare to give the woman a break to have
time for herself is often something women desperately need,
but feel guilty about. If her main support is her mother or
partner and there is conflict in the relationship, it is important
to deal with this. Extra stress does not constitute support even
if the intention is there.
Specific cognitive behavioural or interpersonal strategies in
an individual setting can be helpful, although more research
is needed.4 Referral to a psychologist is worth considering.
Relaxation, yoga and meditation can all have benefits, but
are difficult for many women to implement. Website-based
interventions can be useful such as those provided by the
Centre for Clinical Interventions (www.cci.health.wa.gov.au).

Antidepressants in pregnancy

There are risks with antidepressants in pregnancy5,6, but it
is important to balance these largely unknown and seeming
relatively low risks with the risks of not treating depression.
Anxiety and depression in pregnancy can affect the fetus,
for example a higher cortisol concentration at birth can be
maintained for 10 years.7 Depressed women are also more likely
to smoke, and have poor nutrition and a risk of suicide.

Treatment of perinatal depression

 

Summary

If possible, women at risk of depression should
be identified during pregnancy. They often do
not spontaneously seek help. Early intervention
is important for the health of the woman and
her baby. Psychological interventions such as
support groups are often helpful. Involving the
woman's partner can also assist. Antidepressants
are required in some cases and women with
psychotic symptoms need urgent psychiatric
assessment and treatment.

Introduction

Postnatal depression is better termed perinatal depression as
it often begins antenatally, although it may not be recognised
until the postnatal period. It is a common disorder, with
milder adjustment problems and anxiety affecting some 30%
of women while about 15% of women have more significant
mood disorders, often with anxiety. Women are reluctant to seek
help, but early identification and intervention are essential to
minimise the long-term complications. These include suicide,
chronic depression and marital difficulties, and for the child,
cognitive, emotional and behavioural problems.
Identification
Unless women have previously had depression, they rarely
recognise it in themselves during the perinatal period. For most,
this is their first episode of depression and is unexpected at
a time that is anticipated positively. In the antenatal period it
is all put down to 'the pregnancy' with the presumption that
everything will resolve itself after the baby is born. Historically,
pregnancy was thought to be protective against mental illness
and suicide, however this is not the case. Mental illness is just
less likely to be recognised in pregnancy. Postnatally, there are
many reasons why women do not seek help, or at least not
for themselves. These include the presence of predominant
anxiety rather than depression, a mistaken belief that postnatal
depression is somehow linked to not wanting the baby or being
a bad mother, the stigma of being seen as a bad mother and the
stigma of depression.
Women seek help for the baby, not for themselves. The long
waiting lists in mother and baby units and settling facilities are
testimony to the very real problem perceived by mothers of
their babies having sleeping and feeding difficulties. In some
cases this is the primary problem, but often it is the mother's
reaction, her high unrealistic expectations and her own
depression and anxiety that are the underlying issue.
A key factor in identifying depression is having a suspicion for
the condition particularly in women with risk factors (Box 1).
Ideally, this risk should be detected during pregnancy.
Women with previous perinatal depression or psychosis
are particularly at risk of having another episode with future
pregnancies. Screening for depression with tools such as the
Edinburgh Postnatal Depression Scale can be helpful.1 Many
antenatal clinics and maternal child health nurses do screening
and suggest women with high scores (> 12) see a doctor.
Adjustment disorders have similar symptoms to depression but
fewer, less severe symptoms and with some 'good times' and
an ability to see into the future. These disorders usually resolve
within three months.
Women with depression have symptoms which last longer
than two weeks. They usually have significant anxiety (often
related to the baby and their ability to mother), tearfulness,
and feel easily overwhelmed and unable to cope with even
basic household chores. Biological symptoms (insomnia,
appetite changes) not accounted for by disturbed sleep and
breastfeeding also suggest a more serious disorder. The severity
of symptoms and their impact on the woman's life are the best
guides to the need for intervention.

Risk factors for perinatal depression
High correlation with increased risk
Depression in pregnancy
Past history of affective disorder
Family history of affective disorder
Lack of support – partner, mother
Multiple stressors
Some correlation with increased risk
Perfectionistic personality
Low socioeconomic status
Aboriginal and Torres Strait Islander people
Childhood abuse

Depression should be distinguished from the less common
postpartum psychosis. The latter usually presents in the first few
weeks after birth, with confusion, dramatic mood or psychotic
symptoms, and requires urgent assessment and inpatient
treatment. In all cases if there is a threat to the safety of either
the mother or the infant, referral to specialist care or involving
protective services may be required. For many women with
depression the baby is protective against suicide, but this is not
true for women with postpartum psychosis, and suicide remains
a leading cause of death.

Rationalities

 

When depressive symptoms are recognized, a number of treatment
alternatives are available. If you decide to seek treatment, consultation
with your mental health provider is recommended to determine the
approach best suited to meet your needs. This manual is environmental/
behavioral in nature, which means that it targets changes in your environment
and behavior as a method for improving your thoughts,
mood, and overall quality of life. Although we are focusing on behavior
change, we are not ignoring thoughts and feelings. Instead, we suggest
that negative thoughts and feelings often will change only after
positive events and consequences are experienced more frequently.
Said more simply, it is difficult to feel depressed and have low
self-esteem if you are regularly engaging in activities that bring you a
sense of pleasure and/or accomplishment (see Figure 1).
To place the focus on your behavior and motivation level, we refer
to actions related to your depression and depressive symptoms as
depressed behavior. Accordingly, we refer to positive actions that are
inconsistent with depressed behavior as healthy behavior. In general,
both depressed and nondepressed behaviors occur (a) to obtain or to
acquire something or (b) to avoid or to escape something. Despite this
simple formula, it is sometimes difficult to determine the specific reasons
why we behave in particular ways.

With regard to depressed behavior, possible benefits include the
avoidance of certain unpleasant or stressful activities, other people
completing your responsibilities, or receiving more attention and
sympathy from your family and friends. Because of these immediate
benefits, it is not surprising that depressed behaviors may become
more frequent, especially if the benefits of healthy behavior appear to
be more difficult to achieve and less immediate. Unfortunately, as the
frequency of depressed behaviors increase and the frequency of
healthy behaviors decrease, important life areas may become
neglected (work absences or decreased social contact), and long-term
negative consequences often result. Again not surprisingly, these consequences
produce a downward spiral that may make you feel both
overwhelmed and trapped in your depression.
Assessing reasons for your depressed behavior is not designed to
make you feel badly or guilty. Instead, it is meant to highlight the fact
that the experience of depression often is the result of natural
responses to stressful environmental situations and changes. Indeed,
the depressed behavior you are currently engaging in may be the best
way you know to cope with overwhelming life events and situations.
Nevertheless, we believe that the bestway to stop the downward spiral
of depression is that one must become active first and then the exposure
to more positive experiences will produce positive changes in
thoughts and mood. More positive and adaptiveways of responding to
negative events require one to behave in a way that initially may feel
uncomfortable and awkward. However, persistence and hard work
eventually will produce favorable results.
Is this treatment right for you? This manual can be used independent
of other interventions, and research has shown that it can be effective
for many individuals when used this way. We acknowledge that
262 BEHAVIOR MODIFICATION / April 2001
Figure 1. A diagram outlining the treatment rationale.
for some individuals, however, their depression may be too overwhelming
to presently work toward directly changing their behavior.
Additionally, particular individuals might prefer greater emphasis on
addressing other potential causes of depression including biological,
cognitive (thoughts and feelings), and social factors. In these cases,
the manual may be used as a treatment supplement. Indications that
this manual may be appropriate for you are as follows:

• You are experiencing depressive symptoms.
• You believe that changing your behavior can help change your mood.
• You are willing to actively work toward changing your behavior.
• Other treatment strategies have been ineffective.
• You are worried about potential side effects of medications.

Introduction in the treatment

 

This manual provides a step-by-step outline of a brief behavioral
activation treatment for depression. It is designed for use in treatment
sessions with your counselor, psychologist, psychiatrist, or physician.
It may be used as a complete treatment or as a component of therapy
that may include other therapeutic techniques and possibly medication.
Units 1 through 3 provide you with general information about
depression and the treatment approach taken in this manual, whereas
Units 4 through 6 outline the process of treatment, including assignments
for you to complete. Your treatment provider will assist in customizing
the treatment to meet your individual needs and will help to
ensure that treatment is moving at a comfortable pace.
UNIT 2: RECOGNIZING DEPRESSION
Definition and prevalence of depression. Depression is defined as
an extended period of time (at least 2 weeks) in which a person experiences
depressed mood or a loss of interest or pleasure in activities that
were once enjoyed. Between 10% and 25% of women and 5% to 12%
of men will experience at least one episode of major depression in
their lifetime (Diagnostic and Statistical Manual of Mental Disorders
[DSM-IV], American Psychiatric Association, 1994). Although
depression most often occurs between the ages of 25 and 45, it can
Lejuez et al. / BEHAVIORAL ACTIVATION 259
affect people of all ages, cultures, income, education, and marital
status.
For some people, the onset of depression is clearly related to stressful
life events (e.g., loss of a loved one, financial difficulty, job loss).
For others, the specific causes of depression may be unclear, and onset
may occur without warning. Theorists have proposed that the development
of depressive symptoms is influenced by a variety of behavioral/
environmental, cognitive (i.e., thoughts, beliefs), social, and biological
influences. These factors may act independently or together to
produce and maintain depressive symptoms.
Whether it lasts a couple of weeks or as long as several years, an
episode of depression may produce significant impairment in life functioning
(e.g., unable towork, cook, or take care of children). Psychological
consequences may include decreased optimism/motivation, low
self-esteem, impaired concentration, fatigue, and possibly extreme
behaviors such as self-injury and/or suicide. Medical consequences of
depression may include heart disease, autoimmune disease, substance
abuse or dependence, and impaired nutrition. Individuals with depression
may isolate from others and/or assume a more negative approach
to life that may result in a depletion of social support, divorce,
decreased job satisfaction or unemployment, and educational failure.
Given these possible consequences, identification and treatment of
depression is critical.
If depressive symptoms are severe, major depression may be diagnosed.
Major depression can be distinguished from ordinary “blues”
or “feeling down” by several factors. DSM-IV (American Psychological
Association, 1994) specifies that to meet criteria for a major
depressive episode, there must be a period of at least 2 weeks during
which there is either depressed mood or the loss of interest or pleasure
in nearly all activities. Additionally, at least four of the following
symptoms must be present:
• significant weight loss or weight gain
• decrease or increase in appetite
• insomnia or oversleeping
• feelings of agitation or irritability
• fatigue or loss of energy
• feelings of worthlessness or excessive or inappropriate guilt
260 BEHAVIOR MODIFICATION / April 2001
• diminished ability to think or concentrate, or indecisiveness
• suicidal thoughts or attempts
Although most individuals experience some form of many of the
above symptoms, these symptoms must either result in significant
feelings of distress or interfere with day-to-day functioning (e.g.,
making it difficult to work, manage household or family responsibilities,
or interact socially with other people) for a diagnosis of depression
to be made. Additionally, the depressed mood cannot be a result
of a medical condition or be caused by medications, alcohol, or other
drug use.

A Brief Behavioral Activation Treatment for Depression

 

Despite data supporting use of behavioral activation
in the treatment of depression, there have been fewpublished and easily
accessible resources that provide an explicit, step-by-step protocol
for the provision of a purely behavioral activation treatment.
To address this gap in the literature, we designed the Brief Behavioral
Activation Treatment for Depression (BATD) (Lejuez, Hopko,
LePage, Hopko,&McNeil, in press), which provides clinicians with a
powerful behavioral intervention to treat depression in a succinct and
parsimonious package. Although the principles and processes underlying
BATD are focused on behavioral activation, cognitive and emotional
processes are not ignored. Moreover, although not directly targeted
for change, these cognitive aspects of depression are presumed
to become more adaptive following behavioral activation procedures
and are assessed frequently across sessions as an index of treatment
gains. Finally, we do not deny the potential effects of resulting covert
changes; we merely assert that activation should be the direct target
for change in a cycle that may lead to the long-term remission of
depression.
The advantages of this protocol lie in its ease of implementation,
including the absence of difficult skills for therapists to acquire. Additionally,
this protocol easily is tailored to the ideographic needs of a
particular patient.Within this structure, patients and practitioners collaborate
to identify individualized target behaviors, goals, and
rewards that serve to reinforce nondepressive or healthy behavior.
Finally, considering the restrictions being imposed by health maintenance
organizations, the time-efficient and cost-effective nature of
BATD makes it a viable treatment option.
We developed BATD to specifically target contextual factors that
affect behavior, using the matching law as a guiding principle (Lejuez
et al., in press). According to the matching law (Hernstein, 1961,
1970), the proportion of behavior allocated to one alternative relative
to a second possible alternative is equal to the proportion of obtained
reinforcers on the first alternative relative to the second alternative.
Applied to clinical depression, the matching law suggests that the relative
frequency of depressed behavior compared with nondepressed
256 BEHAVIOR MODIFICATION / April 2001
(i.e., healthy) behavior is proportional to the relative value of reinforcement
provided for depressed behavior compared with nondepressed
behavior (McDowell, 1982). In other words, depression
persists because (a) reinforcement available for nondepressed behavior
is lowor nonexistent, and/or (b) depressed behavior produces a relatively
high rate of reinforcement. Based on this philosophy, the
behavioral activation treatment for depression is designed to increase
exposure to the positive consequences of healthy behavior, thereby
increasing the likely reoccurrence of such behavior and necessarily
reducing the likelihood of future depressed behavior (see Lejuez et al.,
in press, for amore detailed discussion of the matching law conceptualization
of depression).
Preliminary data examining implementation of BATD within clinical
settings supports its effectiveness. First, in several outpatient case
studies (Hopko, Lejuez, McNeil, & Hopko, 1999; Hopko, LePage,
et al., 1999; Lejuez et al., in press) we have shown sizeable decreases
in the Beck Depression Inventory–II (BDI-II) scores using BATD
(pre-BATD = 29.7; post-BATD = 8.7). More recently, we have been
testing the effectiveness of BATD within an inpatient mental health
facility where inpatients received either BATD or supportive psychotherapy
(Hopko, LePage, et al., 1999). Considering the data presently
available, itwas found that the change in BDI-II scores for individuals
receiving BATD (pre-BATD = 34.6; post-BATD = 18.0) was significantly
greater than that for individuals receiving the standard supportive
therapy typically used within the hospital (pre-therapy = 36.6;
post-therapy = 29.9; t (21) = 2.16, p = .04). In future studies, we are
interested in establishing the utility of BATD when compared with
other psychotherapies and pharmacotherapies. Additionally, although
we have no reason to doubt its applicability across other modalities
(e.g., group therapy) or with other populations (e.g., adolescents),
empirical tests of its generalizability are needed.
A step-by-step patient manual for the implementation of BATD is
provided below. The protocol is intended for distribution to the
patient, with the practitioner serving to facilitate the patient’s progress.
Indeed, the intent is to have the patient take responsibility for
change and to actively participate in the course of therapy, with an
emphasis on work outside of the session. Therefore, the primary role
Lejuez et al. / BEHAVIORAL ACTIVATION 257
of the practitioner is to provide an environment supportive of behavior
change and to ensure that the execution of the treatment occurs at a
reasonable pace and is not overwhelming to the patient. The following
is an example of how the treatment rationale might be introduced to
the patient:
You may not presently feel as though you are able to get much done or
that you are always tired and lack motivation. You also may be waiting
to feel better or think more positively before you become more active
and start participating in activities that once brought you pleasure. As
you know, however, getting yourself to feel better is not an easy thing to
do. Therefore, we’d like you to try something different. The idea of the
treatment we are about to begin is that your thoughts and feelings are
affected by your interactions with others and your overall quality of
life. So, we believe that for you to have more positive thoughts and to
feel better, you must first become more active and put yourself into
more positive situations. Although this will be quite difficult right now,
it will become easier as more and more positive experiences occur. The
treatment requires you to work hard, and I understand that you may be
questioning your ability to make changes at this time in your life, but I
will help you through this process, and we will work at a pace at which
you feel comfortable.
The practitioner should initially provide a highly structured environment
and be fairly directive and supportive. Over the course of treatment,
and determined on an ideographic basis, guidance should gradually
be faded. Throughout treatment, and particularly in the initial
stages, the practitioner also should provide appropriate social reinforcement
for treatment compliance and goal attainment.
Treatment generally consists of approximately 10 to 12 sessions. In
earlier sessions that include an explanation of the treatment rationale,
attaining environmental support, and activity and goal selection, sessions
may take as long as 1 hour (Units 1-3). Over time, as the patient
becomes more skilled at monitoring, sessions may be reduced to
between 15 to 30 minutes. Depending on the progress of therapy and
patient comfort with the protocol, less frequent and even shorter sessions,
as well as telephone contact, may be utilized. Following the
introduction of the treatment rationale, patients should be guided in
the collection of baseline activity level and depressive symptom severity
(Unit 4). As a final step in the preparation for the treatment proto-
258 BEHAVIOR MODIFICATION / April 2001
col, patients should be directed toward the identification of contextual
factors that may be influencing the occurrence of depressed behavior.
This process likely will focus on the identification of reinforcers for
depressed and nondepressed behavior, with special attention to the
behavior of friends and family. Once these basic steps have been
engaged, activities can be selected and placed within the framework
described above (Unit 5). Finally, weekly assessment, planning, and
adjustment are used to ensure that the treatment proceeds successfully
(Unit 6).

Major Depression During Conception and Pregnancy

 

Depression is an illness that affects up to 1 in 4 women
at some point in their lives. It often begins when
women are in their 20s and 30s, at the same time they
may be considering having children. If you or someone you
know has major depression, you may be wondering whether it is
safe to become pregnant—especially if you are taking medication
for your symptoms—or safe to continue medication if you
are already pregnant. This guide is intended to answer some
commonly asked questions about the treatment of major depression
while trying to conceive and during pregnancy.
WHAT IS MAJOR DEPRESSION?
Major depression is a mood disorder. Mood disorders are
illnesses that affect a person’s ability to experience normal
mood states. Research suggests that mood disorders are biological
illnesses involving changes in brain chemistry. Emotional
stress can sometimes trigger these changes, though some
individuals may experience depression for no apparent external
cause. The symptoms of major depression include:

• Depressed mood most of the day, nearly every day for 2
weeks or longer and/or
• Loss of interest or pleasure in activities that the person usually
enjoys.
Other symptoms can include:
• Fatigue or lack of energy
• Restlessness or feeling slowed down
• Feelings of guilt or worthlessness
• Difficulty concentrating
• Trouble sleeping or sleeping too much
• Recurrent thoughts of death or suicide.

DEPRESSION DURING PREGNANCY: SPECIAL ISSUES
Contrary to popular belief, pregnancy does not protect a
woman from becoming depressed. About 20% of women
experience some depressive symptoms during pregnancy, and
about 10% of women develop major depression. Women who
have had major depression in the past have a higher risk of
becoming depressed in pregnancy, especially if they stopped
taking antidepressant medication while trying to become
pregnant.
Treating depression in a woman who wants to conceive or is
pregnant is complicated. When pregnancy is not an issue,
psychotherapy can help with milder symptoms, but antidepressant
medication is often needed to bring relief from severe
major depression. However, in pregnancy concerns arise about
using medications to treat depression since they cross the placenta
and may harm the fetus. At the same time, untreated
major depression has serious potential risks for mother and
fetus, since it may lead to poor nutrition, smoking, drinking,
suicidal behavior, prolonged or premature labor, and low birth
weights.
Unfortunately, research information about the safety of
antidepressants in pregnancy is limited because there are important
ethical concerns about conducting such research.
However, many pharmaceutical companies do maintain registries
of pregnant women who have taken their products, and
some hospital clinics publish information on groups of women
who have used antidepressants during pregnancy. These records
provide helpful information about several of the most
widely used antidepressants, although we lack such information
about a number of other antidepressants.
In deciding whether a woman should use antidepressant
medication while pregnant or trying to become pregnant, a
woman and her doctor have to balance the possible risks of the
medication against the severity of the depression. Because our
research knowledge is limited, we surveyed leading experts in
the area of women’s mental health to develop recommendations
based on their best judgments. This article summarizes
the results of this survey.
TREATMENT WHILE TRYING TO CONCEIVE
Many women who have had depression may be taking antidepressants
to prevent symptoms at the time they wish to
become pregnant. Whether the medication should be stopped
depends on how severe the history of depression has been. If a
woman has had only 1 previous episode of depression and has
been feeling well for at least 6 months, the experts recommend
that she taper off medication before trying to conceive. Several
weeks may be required before all traces of medication have
been eliminated. The experts also suggest that continuing or
beginning psychotherapy may be helpful in preventing symptoms
from returning. However, if a woman has a history of
severe major depression with multiple previous episodes, the
experts recommend that she continue medication at full dose
through conception. If she is already taking an antidepressant
for which there is a fair amount of information suggesting that
it is safe (these are listed later), it is fine to continue. However,
if she is taking a medication for which there is little information,
she should switch to a medication thought to be safer.
What about a woman who is depressed, is not receiving
treatment, and wants to conceive? If the depression is mild, the
experts would recommend trying to treat her symptoms with
psychotherapy alone. However, if the symptoms are severe,
whether it is a first episode or 1 of many, a combination of
medication and psychotherapy is advised.
TREATMENT IN THE FIRST TRIMESTER
The first trimester (12 weeks) of pregnancy is a crucial time
when medication can cause malformations of the fetus.
Women may be taking antidepressants at the start of pregnancy
for 1 of the reasons discussed above or may have an
unplanned pregnancy while on medication. If a woman has

TREATMENT OF DEPRESSION IN WOMEN
MARCH 2001 • A POSTGRADUATE MEDICINE SPECIAL REPORT • 111
had only mild symptoms in the past, the experts recommend
gradually stopping the medication over several weeks as soon
as she knows she is pregnant. (But recall that it is a good idea
to stop the medication before trying to conceive, unless a
woman has had multiple episodes of severe depression.) For a
woman who has had multiple past episodes of severe depression,
the experts clearly prefer that she remain on medication
and, if necessary, switch from her current drug to one viewed
as relatively safe. For the in-between case of a woman who has
had only 1 episode, but a severe one, the experts are divided as
to whether to continue or stop the medication. Whether the
woman remains on medication or not, in all these situations,
the experts advise using psychotherapy to help prevent depression
from coming back.
TREATMENT DURING THE SECOND AND THIRD
TRIMESTERS
Later in pregnancy there is not the concern about medication
causing malformation of organs. However, there are still
questions about whether medication might cause a miscarriage
or subtle changes in the early development of the future
child. If there has been a good reason to use medication during
the first trimester (such as recurrent bouts of severe depression),
medication should probably be continued through
delivery, since women who have histories of depression before
or during pregnancy are vulnerable to postpartum depression.
What if a woman who has not been taking medication becomes
depressed? The first step is to start psychotherapy, or
intensify it if already underway. If there is a history of severe
depression, many experts would resume medication at the
first sign of symptoms coming back. If the woman has had
only mild depression in the past, the experts would wait to see
if the depression comes back in full force before starting
medication.
What about a woman with a history of depression, who has
done well off medication through the later stages of pregnancy?
Should medication be restarted to prevent depression
after delivery (postpartum depression)? Experts agree that
preventive treatment is a good idea for women who have had
previous postpartum depression but would wait until the last
month of pregnancy to resume medication.
MEDICATIONS USED TO TREAT DEPRESSION
Many types of antidepressants are available with different
chemical actions and side effects. For the treatment of women
with depression who are trying to conceive or who are pregnant,
the experts recommend a kind of antidepressant that
increases brain levels of a chemical called serotonin. These
medications are called selective serotonin reuptake inhibitors
(SSRIs). SSRIs are currently the most widely prescribed antidepressants
in the world and have been used by millions of
women. There is even evidence that they work more effectively
in women than other antidepressants. It is not a surprise that
many women have therefore become pregnant while taking
SSRIs. Records show that the rate of infants with birth defects
born to women taking SSRIs is no higher than the rate seen in
women who took no medication—about 2%–3%. Thus, there
is no current evidence that SSRIs cause birth defects.
The SSRIs preferred by the experts for use in pregnancy are
fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).
A small number of research studies support these choices.
Fluoxetine, the first of this group to be used in the United
States (since 1987), is the treatment of choice of most experts,
probably because there has been more experience with its use
in pregnancy than with other medications. In addition, there
is research suggesting that exposure to fluoxetine before birth
does not have negative effects on later child development.
Many pregnant women have also taken sertraline and paroxetine
without apparent problems. After we conducted our
survey, researchers reported that another SSRI, citalopram
(Celexa), has a similar profile of apparent safety.
The experts also favor tricyclic antidepressants, another
kind of antidepressant that affects other brain chemicals in
addition to serotonin. Tricyclic antidepressants have been
used for over 40 years. Like SSRIs, extensive use in pregnancy
has not revealed evidence of causing birth defects. Some other
antidepressants have not shown evidence of causing birth
defects but have not been used widely enough in pregnancy
for doctors to feel confident.
What about side effects of SSRI medications?
SSRIs may cause the following side effects: nervousness,
insomnia, restlessness, nausea, diarrhea, and sexual problems.
Side effects differ from 1 person to another. Also, what may
be a side effect for 1 person (e.g., drowsiness) may be a benefit
for someone else (e.g., a woman with insomnia). If you are
having any problems with side effects, tell your doctor right
away. Don’t stop the medication on your own. Your doctor
may try to lower the dose or switch you to a different SSRI.
What kinds of psychotherapy are used to treat depression?
Several types of psychotherapy have been proven effective
in the treatment of patients with major depression in general.
Some researchers have also applied these successfully in pregnancy.
Interpersonal therapy focuses on reducing the strain
that a mood disorder may place on relationships. Cognitivebehavioral
therapy focuses on identifying and changing the
pessimistic thoughts and beliefs that can lead to depression.
When used alone, psychotherapy usually works more gradually
than medication and may take 2 months or more to show
its full effects. However, the benefits may be long-lasting.
A special word about depression with psychosis
A severe form of major depression may include psychotic
symptoms, such as delusions or hallucinations. Depression
with psychosis is a great concern because it may cause a number
of behaviors that compromise the safety of the mother
and her unborn child. For a psychotic depression during any
trimester of pregnancy, the experts recommend combining an
antidepressant with a second medication called an antipsychotic.
Electroconvulsive therapy is also an important option
that can be used safely in pregnancy instead of medication for
this type of depression. The experts would not rely on psychotherapy
alone in this situation.

St John’s wort as a depression treatment

 

 What are the side‐effects of St John’s wort?

The use of St John’s wort as a treatment for depression has created some controversy,
with clinical trials into its safety and effectiveness constantly under review. Generally,
St John’s wort is well tolerated when taken on its own. The most common side‐effects
reported are dry mouth, dizziness, increased sensitivity to sunlight (photosensitivity),
gastrointestinal symptoms and fatigue. Its safety in pregnancy has not been clarified.
Purity of the active ingredients
While St John’s wort is freely available in Australia, the Therapeutic Goods
Administration has warned that the strength of the active ingredients may vary
between preparations, and potentially reduce the effectiveness of other medicines. A
problem with herbal remedies, compared to manufactured drugs, is that the dose of
the active ingredients cannot be precisely controlled.
Does St John’s wort affect other medications?
St John’s wort is known to adversely interact with some medications. Taken in
combination with other drugs, St John’s wort can boost the effect of the other drug,
which then increases the risk of negative reactions. St John’s wort may also impact on
the breakdown of other drugs by reducing their concentration levels in the blood and
hence their effect.
Contraindications can occur with interactions between St John’s wort and
antidepressants, HIV medications, transplant drugs, warfarin (a blood thinning agent),
some heart medications, anticonvulsants used in the treatment of epilepsy, the
contraceptive pill and migraine treatments.
St John’s wort should not be used in conjunction with antidepressant medication.
How does it work?
It is thought that St John’s wort is a reuptake inhibitor of serotonin, dopamine and
noradrenaline, which are chemicals in the brain that are linked to depression and
anxiety. Recent clinical trials have found that St John’s wort was superior to placebo,
or as effective as standard antidepressants (for example, Prozac, Tofranil and Zoloft).
Dosage
It is suggested that 900 mg of St John’s wort is required to effectively reduce
symptoms of non‐melancholic depression. As with other antidepressant medication,
the herbal remedy may take up to four weeks to become effective.