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.
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.
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