Introduction
Depressive disorder is a significant public health concern on a global scale due to its high prevalence level and adverse effects on people’s physical health and social well-being. In the general population, depression is considered a common mood disorder that might lead to adverse outcomes, including suicide. For pregnant women, the risks of having a depressive episode are higher due to the vulnerability of this population in light of the childbearing condition. While psychotherapy and other non-pharmacological approaches to depression treatment might be safe and effective in the long-term perspective, medication treatment remains a common way of treatment. Given the vulnerability and a large number of health-related considerations for this population, pregnant women should be prescribed anti-depressive medications with caution. This paper is aimed at discussing the particularities of pharmacological treatment of depressive disorders in pregnant women to emphasize the importance of addressing the health outcomes of both mothers and infants.
Depression Causes and Symptoms
The causes of depressive disorder are based on internal and external factors and adverse life experiences. In particular, as stated by Maurer et al. (2018), the internal factors that cause depression in the general population include neuroticism, female sex, anxiety episodes, and low self-esteem. As for the external factors, they imply substance use and adverse experiences, such as abuse faced in childhood, grief, chronic medical conditions, traumatic experiences, and other issues (Maurer et al., 2018). The symptoms of this disorder include persistently sad mood, the loss of interest in any events in life, sleep disturbance, the feeling of guilt, energy deficit, insufficient concentration, appetite abnormalities, agitation, and suicidal intentions (Maurer et al., 2018). These symptoms and causes are prevalent for all populations impacted by depressive disorders.
Diagnosis of Depression in Pregnant Women
The diagnosis of the disorder is an essential aspect of proper clinical response to it since timely and accurate identification of the illness enables its effective management and treatment. In particular, in the population of pregnant women, the diagnosis of depression is particularly relevant due to their vulnerability caused by the changes a woman experiences and the implications of the issue on the offspring (Bellantuono et al., 2019). In particular, the prevalence of depression in pregnant women reaches 10%; it is “associated with abnormal development, cognitive impairment, and psychopathology in children” (Maurer et al., 2018, p. 511). The diagnosis of depression in pregnant women is commonly conducted via screening methods, such as the Edinburgh Postnatal Depression Scale and Patient Health Questionnaire, which is used to screen all pregnant women (Maurer et al., 2018; Mesches et al., 2020). These scales are effective multi-lingual tools that allow for the accurate identification of the symptoms.
Medication Treatment Options
When selecting an appropriate pharmacological treatment for depressive disorders in pregnant women, healthcare professionals might consider several options. Antidepressants are the most common treatment option for depression in all populations, including pregnant women. In particular, “selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs),” along with common antidepressants, have the benefits of easy access (Morrison et al., 2019, p. 538). However, there are risks associated with the resistance of patients to these medications and their delayed anti-depressive effect, which might occur long after the onset of treatment.
The US Food and Drug Association (FDA) approves Brexanolone as a safe medication. for peripartum depression (Morrison et al., 2019); however, no psychotropic drug is approved by FDA for pregnant women due to the lack of sufficient clinical proof of their safety (Kimmel et al., 2018). The side effects of such medications include “dry mouth, insomnia, and nausea” (Kimmel et al., 2018, p. 426). The risks of using antidepressants in pregnant women are associated with the threats of miscarriage, structural malformations, growth effects, neonatal outcomes, and long-term effects on children (Mesches et al., 2020). However, since untreated depression might lead to more severe outcomes, the risks of non-treatment should be evaluated against the risks associated with medication intake in an individual manner.
Medication Considerations
When prescribing medications to pregnant women with depression, specific considerations should be addressed. In particular, for Brexanolone, patients’ susceptibility to the sedative effect of the drug and the dosage appropriate to the patient’s symptoms severity should be considered (Morrison et al., 2019). For Trazodone, given the minor risks of fetus development impairments, individual particularities of depression severity should be considered (Kimmel et al., 2018). Finally, in the case of Bupropion, since this drug shows no adverse outcomes for the fetus in the first trimester of pregnancy, it is recommended to consider prescribing it during this period (Kimmel et al., 2018). Overall, the side effects, intended outcomes, and compatibility with other medications in each individual case should be addressed when prescribing these drugs.
Monitoring
Given the likelihood of alterations in the health conditions of pregnant women when undergoing pharmacological treatment of depression, several indicators should be regularly monitored to ensure proper adjustments. In particular, according to Mesches et al. (2020), depression symptom recurrence should be monitored. In addition, the level of reproductive hormones, such as estradiol, estrogen, and progestin, that might be altered by the medications should be monitored to allow for dosage adjustment (Kimmel et al., 2018). Furthermore, monitoring symptoms frequently, especially in the second and third trimesters, and dose increases with early symptoms of relapse is a strategy to avoid symptom recurrence” (Mesches et al., 2020, p. 7). Since drugs for depression treatment have a risk of affecting the fetus, its proper development should be monitored using available methods. Thus, regular and frequent laboratory testing and screening for comorbidities should be implemented to reduce risks of health impairments for the mother and fetus.
Special Considerations
In addition to medication considerations, special aspects should be taken into account when prescribing medication for depression in pregnant women. In particular, from the legal perspective, all medications should be FDA approved and given to patients with consent (Mesches et al., 2020). In terms of ethical considerations, healthcare professionals should apply the principles of privacy and autonomy when considering treatment appropriate to the individual health particularities of the patients. Cultural considerations in medication prescribing should be based on the healthcare professional’s awareness of the prevalence of comorbidities in the served cultural group (Kimmel et al., 2018). Finally, the social determinants of health, such as socio-economic status, education level, and environment, should be considered in every individual case.
Follow Up
Given the severity of depression implications for the vulnerable population of pregnant women, the medication treatment might be insufficient without proper follow-up procedures. Indeed, according to Mesches et al. (2020), women exposed to pharmacological treatment of depressive disorders should be assisted by healthcare professionals throughout a long-term follow-up period to identify potential changes in their health and the health of their infant. In this period, the persistence of depressive symptoms and the management effectiveness should be evaluated to make appropriate adjustments. Moreover, in the local community, pregnant women with depression might obtain support from medical facilities, families, non-profit organizations, and online resources providing information about mental health. Overall, the monitoring and continuous screening of depressive symptoms in women with a history of depressive disorder should be prioritized to ensure that their vulnerability status is adequately addressed.
Prescription Examples
The following examples of medication prescriptions might apply to the population of pregnant women with depressive disorder symptoms:
- Brexanolone: for the inpatient setting, “intravenous infusion at 60 μg/kg/h” (Morrison et al., 2019, p. 5).
- Trazodone: “50–400 mg, ½ tablet (25 mg)-100 mg for sleep” should be taken with caution, ensuring that the benefits outweigh the risks in the individual case (Kimmel et al., 2018, p. 423).
- Bupropion: “150–450 mg, increase by 150 mg, SR BID dosing” (Kimmel et al., 2018, p. 423).
The dosage should be reviewed over time and prescribed individually with caution to the individual particularities of each patient.
Conclusion
In summation, depressive disorder is a threatening mental health condition that exposes pregnant women to significant risks to their health and the health of their offspring. Timely diagnosis and treatment of the condition should be prioritized for this population, given the high level of adverse outcomes when untreated, including suicide, miscarriage, and fetus impairments. Pharmacological treatment is characterized by significant risks and side effects, which necessitates weighing the benefits against the risks of non-treatment. For that matter, individual considerations should be in place when prescribing a particular drug to treat depression in pregnant women.
References
Bellantuono, C., Martellini, M., & Orsolini, L. (2019). General approach to pharmacological treatment: during the perinatal period. In Perinatal psychopharmacology (pp. 55-66). Springer, Cham.
Kimmel, M. C., Cox, E., Schiller, C., Gettes, E., & Meltzer-Brody, S. (2018). Pharmacologic treatment of perinatal depression. Obstetrics and Gynecology Clinics, 45(3), 419-440.
Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: Screening and diagnosis. American Family Physician, 98(8), 508-515.
Mesches, G. A., Wisner, K. L., & Betcher, H. K. (2020). A common clinical conundrum: Antidepressant treatment of depression in pregnant women. Seminars in Perinatology, 44(3), 1-13.
Morrison, K. E., Cole, A. B., Thompson, S. M., & Bale, T. L. (2019). Brexanolone for the treatment of patients with postpartum depression. Drugs of Today, 55(9), 537-544.