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    Feb.14.2025

    Major Depressive Disorder in Pregnancy

    Synopsis

    Key Points

    • Depressive disorders in pregnancy are characterized by sad, empty, or irritable mood and somatic and cognitive changes that affect functioning in a pregnant patient; these disorders differ in duration, timing, and cause
    • Diagnosis of major depressive disorder is based on DSM-5-TR criteria. Patient must have several specific symptoms including either depressed mood or anhedonia lasting at least 2 weeks
    • May be underdiagnosed and undertreated during pregnancy. Initial presentation may occur during pregnancy or preexisting disease manifestations may change during pregnancy
    • Can initially use screening tools to help identify patients at risk for depression; most commonly used screening tools in perinatal populations include Edinburgh Postnatal Depression Scale,r1Patient Health Questionnaire-9,r2 and Postpartum Depression Screening Scaler3
    • Confirm diagnosis by fulfilling DSM-5-TR criteria for major depressive disorder
    • Treatment decisions surrounding the use of pharmacologic management must be weighed against the risk of exposure to untreated depression and psychotropic medication, both of which may have potential adverse maternal and fetal effects r4
    • Treatment strategy is often based on maternal symptom severity and functioning; primary treatment modalities include psychotherapy and pharmacologic treatment r4
    • Preferred psychotherapeutic modalities include interpersonal therapy and cognitive behavioral therapy; selective serotonin reuptake inhibitors are the preferred pharmacotherapeutic option
    • Patients who are being treated for depression before pregnancy generally should continue taking the prescribed antidepressant that is successfully managing symptoms throughout pregnancy
    • Complications affecting pregnancy and fetal outcome can occur because of untreated or undertreated maternal depression and use of medication during pregnancy
    • Antidepressant medications used in pregnancy are not major teratogens (except paroxetine, which possibly increases the risk of fetal cardiac septal defects with first-trimester exposure)
    • Primary adverse effects related to selective serotonin reuptake inhibitor use in pregnancy include risk for poor neonatal adaptation syndrome and slightly increased risk for persistent pulmonary hypertension of the newborn and preterm birth
    • Most guidelines endorse routine perinatal screening for depression

    Urgent Action

    • Urgent intervention and hospitalization are required for patients with severe depression symptoms, psychosis, or suicidal ideation or attempts

    Pitfalls

    • Diagnosis can be challenging during pregnancy because some somatic symptoms included in DSM-5-TR criteria for diagnosis of depression overlap with normal pregnancy-related changes (eg, sleep changes, appetite changes, fatigue)
    • Always exclude bipolar disorder before initiating any pharmacotherapy for depression, as treatment with antidepressant monotherapy may precipitate mania, rapid cycling, or psychosis in patients with bipolar disorder r5
    • Always consider substance use as a potential contributor to major depressive disorder and a potential consequence of it
    • Management must be individualized and must balance the risks of medication exposure during pregnancy against the risks of untreated maternal depression
    • Financial concerns represent a significant barrier to adequate mental health treatment for a significant proportion of patients r6

    Terminology

    Clinical Clarification

    • Depressive disorders in pregnancy are characterized by sad, empty, or irritable mood and somatic and cognitive changes that affect functioning in a pregnant patient; these disorders differ in duration, timing, and cause
    • Depression that occurs during pregnancy is also known as antenatal depression; perinatal depression is a term that encompasses both antenatal depression as well as depression that occurs in the immediate postpartum period (postpartum depression) r7
    • Major depressive disorder during pregnancy (antenatal depression) is the focus of this Clinical Overview; postpartum depression is addressed in more detail separately d1
    • Up to 15% of females meet criteria for depression at some point during pregnancy or the postpartum period r8
    • Diagnosis of major depressive disorder is based on DSM-5-TR criteria. Patient must have a minimum of 5 of the following symptoms and at least 1 needs to be either depressed mood or anhedonia lasting at least 2 weeks: r9
      • Depressed mood present most of the day
      • Markedly reduced interest or pleasure in all or almost all activities for most of the day
      • Significant weight loss or gain or appetite increase or decrease
      • Observable psychomotor agitation or retardation (eg, slowed speech, thought, movement) nearly every day
      • Insomnia or hypersomnia nearly every day
      • Fatigue or lack of energy nearly every day
      • Sense of worthlessness or guilt (which may be delusional)
      • Difficulty concentrating or making decisions
      • Recurrent thoughts of death, dying, or suicide
    • Depressive disorders may be underdiagnosed and undertreated during pregnancy; they may initially present during the perinatal period or preexisting disease manifestations may change during pregnancy r8r10

    Classification

    • Depressive disorders are all characterized by sad, empty, or irritable mood and somatic and cognitive changes that affect functioning; however, they differ in duration, timing, and cause
    • DSM-5-TR classifies depressive disorders as follows: r11
      • Major depressive disorder
      • Persistent depressive disorder (dysthymia)
      • Premenstrual dysphoric disorder
      • Substance/medication-induced depressive disorder
      • Disruptive mood dysregulation disorder
      • Depressive disorder related to another medical condition
      • Other specified and unspecified depressive disorders

    Diagnosis

    Clinical Presentation

    History

    • Disease onset
      • May occur for the first time during pregnancy or patient may have history of depression c1
    • Symptoms may include: r12
      • Dysphoria (feelings of sadness or hopelessness) c2
      • Anhedonia (loss of interest in pleasurable or usual activities) c3
      • Insomnia or hypersomnia c4c5
      • Sense of guilt or poor self-esteem c6c7
      • Difficulty concentrating and memory impairment c8c9
      • Negative thoughts about the future c10c11
      • Excessive weight loss or gain c12c13
      • Increased or decreased appetite c14c15
      • Preoccupation with physical symptoms (eg, fatigue, headache, nausea, diarrhea, constipation)r13 and pain c16c17c18c19c20c21c22
      • Disinterest in or excessive anxiety about pregnancy c23c24
      • Lack of adherence to prenatal care c25
      • Talk of suicide or death c26c27
      • Suicidal ideation or passive death wish c28c29
    • May be unclear whether some of the symptoms are due to depression or normal pregnancy-related changes r12
      • Some somatic symptoms commonly associated with pregnancy overlap with symptoms of depression (eg, sleep and appetite disturbances, diminished energy, decreased libido) r14r15c30c31c32c33
      • Attention to certain symptoms not common to pregnancy may be most helpful (eg, disinterest in pregnancy, excessive guilt, dysphoria, anhedonia, impaired concentration, suicidal ideation) r15c34c35c36c37c38c39
      • Patients often present with anxiety (eg, excessive generalized worries, pervasive worries that are difficult to control, panic attacks) c40c41
    • Other important patient history factors: r13
      • Suicidal ideation with or without plan c42c43
      • Patient medical history and/or family history may include diagnosis of depression or other psychiatric disorder c44c45
      • Tobacco, alcohol, or other drug use c46c47c48c49
      • Social history may uncover current stressors (eg, marital discord, domestic violence, occupational stressors, limited social support) c50c51c52c53c54
      • Limitation or decline in social, occupational, or academic functioning c55c56c57
      • Limitation or decline in self-care may be present (eg, lack of adherence to prenatal care plan, poor nutrition) c58c59c60

    Physical examination

    • General physical examination may show: r13
      • Weight loss, weight gain, or evidence of poor nutrition c61c62c63
      • Evidence of self-harm (eg, healed lacerations, scars on trunk or extremities) c64c65c66
      • Stigmata of trauma, self-injury, or drug use c67c68c69
      • Evidence of self-neglect with poor personal hygiene r13c70c71
    • Mental status findings may include: r13
      • Poor or no eye contact c72
      • Speaking in low tones or slowly c73
      • Psychomotor retardation and flat affect c74
      • Depressed mood and crying c75c76
      • Sadness, hopelessness, preoccupation with death, suicidal ideation c77c78c79

    Causes and Risk Factors

    Causes

    • Cause is unknown but is postulated to involve a combination of genetic susceptibility, structural and functional brain abnormalities, psychosocial adversity in childhood, and recent or ongoing psychological stress r16c80c81c82c83

    Risk factors and/or associations r9

    Age
    • Adolescent and young adult pregnant patients are at higher risk for prenatal depression r4r17c84c85
      • Up to a quarter of pregnant adolescents may develop major depression during pregnancy r18
    Genetics
    • Major depressive disorder is a multifactorial disorder with genetic susceptibility c86
    • Greatest risk for major depressive disorder is observed in families with early age at onset r19c87
    Ethnicity/race
    • In the United States, there is a higher incidence in Black, Hispanic, and Asian American populations compared with White populations r4c88c89c90c91
    Other risk factors/associations
    • Pregnancy-related associations
      • Overall, pregnancy does not appear to be a distinct period when increased numbers of patients are depressed compared with the entire span of reproductive years; however, some females may be at increased risk for a major depressive episode during the perinatal period r4c92
      • Pregnancy and the postpartum period are associated with risk for relapse in patients who previously experienced major depression c93c94
        • Discontinuing antidepressants during pregnancy is associated with greater risk for relapse in females with severe depression r8
        • In females with milder forms of depression, risk for onset of a major depressive episode during pregnancy seems to be similar whether or not they continue antidepressant medication r20
      • There is an increased prevalence of depressive disorders among females with high-risk pregnancies due to obstetric complications such as threatened preterm labor, preeclampsia, oligohydramnios, and gestational diabetes r21r22c95c96c97c98c99
    • Risk factors for prenatal depression (in addition to adolescence and ethnicity)
    • Risk factors for depression relapse during pregnancy in patient with history of depression before conception r4
      • Discontinuation of antidepressant medication during pregnancy c121
      • Longer duration of illness c122
      • Previous history of relapse c123
      • Relapse episode within 6 months before conception c124
      • Early age at onset of a mood disorder c125
      • Multiple past episodes of depression c126

    Diagnostic Procedures

    Primary diagnostic tools

    • Suspect diagnosis in pregnant patients presenting with manifestations of depression c127
    • Initially may use screening tools to identify patients at risk for depression
      • Edinburgh Postnatal Depression Scale,r1Patient Health Questionnaire-9,r30Patient Health Questionnaire-2r30, and Postpartum Depression Screening Scaler3 are screening tools commonly used to assess patients during the perinatal period r26r27r28r29c128c129c130
      • Patients who screen positive for possible depression require full diagnostic interview with focus on DSM-5-TR criteria and comprehensive psychosocial risk factor assessment r4c131c132
      • Strongly consider referral to a psychiatrist for patients with severe depressive symptoms, psychosis, suicidal and homicidal ideation or attempts, significant comorbidity (eg, substance use), and suspected bipolar disorder
    • Exclude alternative diagnoses
      • Consider laboratory testing (eg, thyroid function tests, CBC, biochemistry, urine or serum drug screen) to exclude conditions that may produce or exacerbate mood symptoms r31c133c134c135c136c137
      • Assess for conditions that may initially mimic depression (eg, bipolar disorder, substance use) and comorbidities that affect treatment decisions (eg, anxiety disorders, substance use) d2
        • Particularly important to screen for bipolar disorder before initiating any pharmacotherapy for depression, as treatment with antidepressant monotherapy may precipitate mania, rapid cycling, or psychosis in patients with bipolar disorder r5
    • Confirm diagnosis by fulfilling DSM-5-TR criteria for major depressive disorder r11c138
      • Diagnosis can be challenging during pregnancy because some somatic symptoms associated with depression overlap with normal pregnancy-related symptoms (eg, sleep changes, appetite changes, fatigue) r17
      • This can be done with either a self-administered or clinician-administered instrument such as the Mood Disorder Questionnaire or Composite International Diagnostic Interview, respectively. Because bipolar disorder and depression both include depressive symptomatology, and because hypomania or mania may have anxiety-like features, bipolar disorder diagnoses are often missed, with symptoms attributed to these more common diagnoses

    Procedures

    c139

    Other diagnostic tools

    • DSM-5-TR criteria for major depressive disorder r11c140
      • At least 5 of the following symptoms are present nearly every day during the same 2-week period and represent a change from previous functioning; at least 1 symptom must be either depressed mood or loss of interest or pleasure
        • Depressed mood present most of the day, either reported by patient or observed by others
        • Markedly reduced interest or pleasure in all or almost all activities for most of the day
        • Significant weight loss or gain or increase or decrease in appetite
        • Observable psychomotor agitation or retardation (eg, slowed speech, thought, movement) nearly every day
        • Insomnia or hypersomnia nearly every day
        • Fatigue or lack of energy nearly every day
        • Sense of worthlessness or guilt (which may be delusional)
        • Difficulty concentrating or making decisions
        • Recurrent thoughts of death, dying, or suicide
      • Symptoms cause clinically significant distress or impaired social, occupational, or other types of functioning
      • Not attributable to physiologic effects of a substance or medical disorder
      • Not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other psychotic disorders
      • Patient has never had a manic or hypomanic episode
    • Assessment of severity c141
      • Subjective assessment of severity is often based on frequency of symptoms and impact on functioning
      • Objective measures suggesting degrees of severity include:
        • Mild to moderate
          • 2 to 4 or more depressive symptoms r32
          • Generally distressed but able to continue most activities (mild) or having great difficulty continuing activities (moderate) r14r32
          • Score of less than 15 points on Patient Health Questionnaire-9 r2
          • Absence of suicidal behavior, psychotic features, or significantly impaired functioning
        • Moderate to severe
          • Score of 15 to 19 points on Patient Health Questionnaire-9 r2
        • Severe
          • At least 7 depressive symptoms r17r32
          • Score of 20 or more on Patient Health Questionnaire-9 r2
          • Number of symptoms is substantially in excess of that required to make the diagnosis r11
          • Intensity of symptoms is seriously distressing and unmanageable r11
          • Symptoms markedly interfere with social and occupational functioning r11
          • Presence of suicidal ideation or attempts or psychotic features
    • Screening tools for depression in pregnancy
      • Positive screening result is not diagnostic; screening tools are intended to identify females who warrant further evaluation r17c142
        • Follow up a positive screening result with a detailed diagnostic interview with focus on DSM-5-TR criteria and assessment of psychosocial risk factors r4
      • Most commonly used screening tools:
        • Edinburgh Postnatal Depression Scale r1c143
          • Self-report, 10-item questionnaire r33
          • Validated for both prenatal and postnatal use;r17 originally developed to screen for possible postnatal depression r4
          • Excludes some nonspecific somatic symptoms common during the perinatal period even in the absence of depressive disorders r26
          • Scores range from 0 to 30 r33
            • Score of 10 to 13 or higher suggests possible depressive or anxiety disorder r4r33
          • Final item specifically addresses thoughts of self-harm and suicidal ideation; any score above 0 on this item warrants full risk assessment aimed at gaining better understanding of likelihood of self-harm r26r34
          • Sensitivity ranges from 80% to 90%, depending on the threshold defined for positive score r26
          • Edinburgh Postnatal Depression Scale items and scoring.Begin screening with an introductory dialogue such as, "We would like to know how you are feeling during your pregnancy. Please underline the answer that comes closest to how you have felt in the past 7 days, not just how you feel today." Scores range from 0 to 30; a score of 10 to 13 or higher suggests possible depressive or anxiety disorder. Any score above 0 on the last item warrants full risk assessment.Adapted from Cox JL et al: Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 150:782-6, 1987.
            ItemAnswer (score 0)Answer (score 1)Answer (score 2)Answer (score 3)
            I have been able to laugh and see the funny side of thingsAs much as I always couldNot quite as much nowDefinitely not so much nowNot at all
            I have looked forward with enjoyment to thingsAs much as I ever didRather less than I used toDefinitely less than I used toHardly at all
            I have blamed myself unnecessarily when things went wrongNo, neverNot very oftenYes, some of the timeYes, most of the time
            I have been anxious or worried for no good reasonNo, not at allHardly everYes, sometimesYes, very often
            I have felt scared or panicky for no very good reasonNo, not at allNo, not muchYes, sometimesYes, quite a lot
            Things have been getting on top of meNo, I have been coping as well as everNo, most of the time I have coped quite wellYes, sometimes I have not been coping as well as usualYes, most of the time I have not been able to cope at all
            I have been so unhappy that I have had difficulty sleepingNo, not at allNot very oftenYes, sometimesYes, most of the time
            I have felt sad or miserableNo, not at allNot very oftenYes, quite oftenYes, most of the time
            I have been so unhappy that I have been cryingNo, neverOnly occasionallyYes, quite oftenYes, most of the time
            The thought of harming myself has occurred to meNeverHardly everSometimesYes, quite often
        • Patient Health Questionnaire-9 r2c144
          • Self-report, 9-item questionnaire r2r35
          • Validated for detection of possible prenatal depression r4
          • Score of 10 or higher suggests possible depression r4
        • Patient Health Questionnaire-2 r30
          • Abbreviated version of Patient Health Questionnaire-9 consisting of the first 2 items from the longer questionnaire; assesses the degree to which an individual has experienced depressed mood or anhedonia in the past 2 weeks
          • Designed specifically for screening
          • Widely used in primary care due to convenience and brevity
          • Patients who screen positive should be assessed further with the Patient Health Questionnaire-9, another standardized depression inventory test, or full diagnostic interview using standardized criteria
        • Postpartum Depression Screening Scale r3c145
          • Self-report, more extensive inventory comprising 5 items in each of 7 dimensions: r26
            • Sleeping and eating
            • Anxiety and insecurity
            • Emotional lability
            • Cognitive impairment
            • Loss of self
            • Guilt and shame
            • Self-harm thoughts
          • Validated for detection of possible perinatal depression r26
          • Score of 60 or higher identifies significant symptoms of depression; score of 80 or higher is a positive screening result for major depression r26
      • Other available tools:
        • Beck Depression Inventoryr36c146
          • Self-report questionnaire; measures intensity, severity, and depth of common depression symptoms r27
          • Standard test has 21 questions; a shorter 7-question version is optimized for office screening use r27
        • Hamilton Depression Rating Scale c147
          • Observer-rated scale designed to be administered by health care professionals r27
        • Major Depression Inventory c148
          • Self-report questionnaire; incorporates both the ICD‐10 symptoms of depression and the DSM-IV symptoms of major depression r29

    Differential Diagnosis

    Most common r37

    • Normal pregnancy-related changes c149c150
      • Some somatic symptoms common during pregnancy overlap with those of major depressive disorder
      • Changes in sleep patterns, appetite, and energy level, as well as decrease in libido, are not uncommon during pregnancy
      • Changes associated with decline in function (eg, loss of energy resulting in inability to get out of bed or attend scheduled prenatal visits, lack of appetite resulting in poor weight gain) suggest major depressive disorder rather than normal pregnancy-related changes
      • Focus on evaluation of depression-related mood and cognitive symptoms (eg, dysphoria, anhedonia, excessive guilt, impaired concentration, suicidal ideation) may help differentiate normal pregnancy changes from symptoms of depression
      • Differentiated by clinical history and DSM-5-TR criteria
    • Persistent depressive disorder (dysthymic disorder) c151
      • Mental disorder characterized by depressive symptoms that do not meet the DSM-5-TR criteria for major depressive disorder
      • Fewer symptoms than major depressive disorder, and symptoms are of variable duration
      • Episodes of major depressive disorder may be interspersed throughout patient's lifetime
      • Differentiated by clinical history and DSM-5-TR criteria
    • Bipolar disorder r38c152d2
      • Mood disorder characterized by at least 1 lifetime episode of mania or hypomania and 1 major depressive episode
      • Patients who have major depression should be carefully screened for bipolar disorder r39
        • 15% of patients with major depression have bipolar disorder
        • Bipolar disorder does not respond to antidepressants; therefore, differentiation is crucial
      • Family history of bipolar disorder may lead to heightened suspicion for illness
      • Presence of mania or hypomania is the cardinal feature that distinguishes bipolar disorder from major depressive disorder
        • May be critical to speak with family or significant other to obtain some insight into possible prior episodes of hypomania or mania; patient self-report of these episodes is often lacking
      • Differentiation can be challenging; diagnosis is based on clinical history and DSM-5-TR criteria
    • Adjustment disorder r40c153
      • Temporary, short-term, nonpsychotic mental response to an event or situation, such as a divorce, a death in the family, a disappointment, or a failure
      • Symptoms can include sadness, anxiety, insomnia, poor concentration, or poor performance in school
      • Symptoms persist for no longer than 6 months after termination of stressor and do not meet criteria for another mental disorder
      • Differentiated by clinical history and DSM-5-TR criteria
    • Schizophrenia c154d3
      • Mental disorder characterized by significant distortion in thinking, perception, speech, and behavior
      • May cause altered mood and depression in addition to psychotic symptoms
        • Differentiating features are psychotic symptoms that occur in the absence of symptoms of a mood episode
      • Differentiated by clinical history and DSM-5-TR criteria
    • Borderline personality disorder c155d4
      • Personality disorder characterized by mood swings, recurrent suicidal ideation, and impulsive behavior
      • Typically associated with affective instability, unstable personal relationships, and transient stress-related cognitive impairment
      • Differentiated by clinical history and DSM-5-TR criteria
    • Hypothyroidism r41c156d5
      • Clinical state induced by inadequate synthesis and secretion of thyroid hormone
      • May result in symptoms of major depressive disorder, in addition to signs and symptoms of slow metabolism (eg, dry skin, brittle hair, weight gain)
      • Differentiated by clinical findings and thyroid function test results
    • Substance- or medication-induced mood disorders c157d6
      • Characterized by significantly depressed mood that develops after use of medications or illicit substances (eg, stimulants, alcohol), resulting in psychosocial impairment d7
      • Mood symptoms are typically confined to, and change in parallel with, periods of substance intoxication or withdrawal
      • Differentiated by clinical history and urine or serum toxicology results

    Treatment

    Goals

    • If patient is suicidal, take steps to protect from self-harm as needed r35
    • Stabilize mood and return patient to normal psychosocial functioning r35
    • Encourage adherence to treatment to minimize relapse or recurrence r35
    • Consider pharmacotherapy when risks of untreated illness are greater than risks of pharmacotherapy during pregnancy r42
    • Address and minimize any complications such as malnutrition and substance use r35

    Disposition

    Admission criteria

    • Indications for admission include:
      • Suicidal or homicidal ideation with plan and intent or suicide attempts r43
      • Substance withdrawal or intoxication r43
      • Severe symptoms (eg, severe delusions, psychosis, catatonic behavior) r43
      • Inability to care for self r43
      • Undergoing electroconvulsive therapy r43
      • Consider for patients at very high risk for relapse r23
    • Partial hospital admission (intensive outpatient treatment) may be appropriate for some patients r43

    Recommendations for specialist referral

    • Optimal approach during pregnancy is multidisciplinary management involving mental health specialist, obstetrician, primary care clinician, and social worker and/or case manager r4
      • Integrated management is particularly ideal for patients who require both psychotherapy and pharmacotherapy r10
    • Consult a psychiatrist or mental health professional specializing in care of pregnant patients if a patient exhibits any of the following:
      • Suicidal or homicidal ideation or attempts
      • Severe depression
      • Delusions or hallucinations
      • Catatonia
      • Substance use
      • Suspected bipolar disorder
      • Depression that has not responded to appropriate drug therapy

    Treatment Options

    Treatment is individualized and often based on severity of illness coupled with level of functioning

    • Little rigorous evidence is available to firmly direct treatment decisions
      • A 2021 systematic review of perinatal pharmacologic interventions published by the Agency for Healthcare Research and Quality noted that few studies on the benefit of pharmacotherapy have been performed in pregnant and postpartum women; many studies have reported on harms but are of low quality r44
    • Balance clinical judgment regarding treatment decisions with risks of medication exposure during pregnancy and risks of untreated maternal depression r4r45
    • Recommend treatment based on severity of depression
      • Mild to moderate depression (eg, absence of either suicidal behavior or significant impairments in functioning)
        • Guidelines recommend either psychotherapy or antidepressant medication as first-line treatment r10r46r47r48
        • Psychotherapy alone is typically appropriate for mild symptoms r49
      • Moderate to severe depression
        • Guidelines often recommend pharmacotherapy in addition to psychotherapy, particularly in the presence of functional limitations and diminished ability for self-care r10r15

    Primary modes of treatment include nonpharmacologic measures and pharmacologic treatment

    • Nonpharmacologic treatment measures
      • Psychotherapy is a first-line treatment for patients with mild to moderate major depressive disorder during pregnancy r47r48r49r50
        • Preferred psychotherapeutic options include cognitive behavioral therapy and interpersonal therapy r7r51r52
        • Psychotherapy is moderately effective and may reduce or obviate need for medications r4
        • Psychotherapy may be effective as:
          • Single modality for mild to moderate depression r4r53
          • Adjunct treatment of depression necessitating psychotropic medication r4
      • Optimize other nonpharmacologic treatment options r4r7
        • May include exercise, stress reduction techniques (eg, yoga, mindfulness), and optimization of general wellness measures (eg, nutrition, sleep), as well as social support structure
    • Pharmacologic treatment
      • No randomized trials have evaluated the efficacy or safety of pharmacotherapy for depression during pregnancy r47
      • If medication is required, consider enrolling a US patient in the National Pregnancy Registry for Antidepressants r54
        • Information collected by registry can help improve safety information for medicines used during pregnancy; information collected may be used to update drug labeling
      • Multiple observational studies support a favorable safety profile for selective serotonin reuptake inhibitors r47
      • Preferred first-line treatment for antidepressant-naive patients is a selective serotonin reuptake inhibitor r20r23r42r45r47
        • Options include sertraline, fluoxetine, fluvoxamine, vilazodone, citalopram, and escitalopram r20r42
          • Sertraline and citalopram are generally preferred owing to their favorable lactation profiles r55
          • Overall, selective serotonin reuptake inhibitors are not considered to be major teratogens r4r8r42
            • Exception is paroxetine, which is generally avoided owing to some reports of cardiovascular malformations (ie, septal defects) with first-trimester exposure. Data are mixed, however, and some publications have reported no increased risk of such abnormalities r44r49r56
            • Where any associations between selective serotonin reuptake inhibitors and congenital abnormalities have been reported, the absolute magnitude of the risk is small, and data are inconsistent owing to multiple confounding variables r8
        • Serotonin-norepinephrine reuptake inhibitors (eg, venlafaxine, duloxetine) are reasonable alternatives
      • If a patient has been effectively treated with an antidepressant of any class in the past, that prior medication is the preferred agent for current treatment r47
      • Other options (with more limited data about safety in pregnancy) for depression not responding to selective serotonin reuptake inhibitors, include: r10r42
        • Bupropion
        • Mirtazapine r57
        • Tricyclic antidepressants; nortriptyline is often preferred owing to lower tendency for anticholinergic adverse effects r56
          • Tricyclic antidepressants may be helpful for patients with concomitant agitation; agents with the fewest anticholinergic effects (ie, nortriptyline, desipramine) are preferred for pregnant patients
          • Overall, tricyclic antidepressants are not associated with congenital anomalies, with the possible exception of clomipramine, which is associated with increased risk of congenital cardiac defects r4
      • Monoamine oxidase inhibitors are discouraged during pregnancy due to lack of safety data, as well as risk of hypertensive crisis when combined with tocolytics
      • Several of the newest approved agents for major depressive disorder, including vortioxetine (approved in 2013), combination dextromethorphan/bupropion (approved in 2022), and gepirone (approved in 2023), are generally not recommended for use during pregnancy due to limited human safety data and/or evidence of fetal harm in animal studies r58r59r60
      • General principles guiding psychotropic medication use during pregnancy:
        • Limit number of exposures
          • Primary goal is to achieve remission (euthymia) so that the fetus is not exposed to effects of both maternal depression and medication r45
          • Preference is to maximize dose of a single drug rather than provide lower doses of multiple drugs r45
        • Preferred medication profile includes the one with the best safety data, few metabolites, higher protein binding to decrease placental passage, and few interactions with other medications r4
        • Consider patient history of medication response; preferentially prescribe medication that has proven effective for this patient in the past (eg, a particular selective serotonin reuptake inhibitor that has helped before) r45
        • Use the lowest effective therapeutic dose r10r45
        • Avoid discontinuing an effective selective serotonin reuptake inhibitor antidepressant during pregnancy r45
          • Tapering these medications during pregnancy puts patient at increased risk for prenatal relapse and postpartum depression and generally is not recommended outside certain scenarios r45
        • Adjust selective serotonin reuptake inhibitor dosing based on clinical symptoms; dose adjustments are frequently needed during the second and third trimesters r45
          • Multiple pharmacokinetic changes in selective serotonin reuptake inhibitor metabolism occur in the second and third trimesters, leading to lower serum drug concentrations r45
          • Often need to increase dose in later stages of pregnancy to maintain therapeutic effect r4
          • Serum drug concentrations return to prepregnancy levels after delivery; decrease in dose may be appropriate in postpartum period r45
        • Use of selective serotonin reuptake inhibitors during the third trimester may be associated with the following: r4
          • Poor neonatal adaptation syndrome r61
            • Irritability
            • Insomnia
            • Rigidity or limpness
            • Tremors
            • Seizures
            • Respiratory distress
          • Small increased risk of persistent pulmonary hypertension of the newborn and preterm deliveryr62r63
          • Newborns exposed to selective serotonin reuptake inhibitors have also been shown to have lower birth weights and Apgar scores at delivery r64
        • Experts usually recommend continuing medication used during pregnancy while breastfeeding; this continuation may minimize potential adverse manifestations in neonates and infants r10r17

    Considerations for patients who do not respond to initial management

    • Definitions of treatment-refractory depression vary r65
      • Most experts agree that a patient has treatment-refractory depression when a response has not been observed with at least 2 antidepressant regimens of adequate dose and duration
    • Assess for alternative explanation before considering alternative treatment
      • Verify correct diagnosis
      • Confirm adequate dose and duration of treatment (antidepressants may take 6-7 weeks to reach full benefit)
      • Verify treatment adherence
      • Reassess for comorbidity (eg, anxiety disorder, substance use)
      • Evaluate for worsening stress or new life stressor
    • Consult a mental health specialist to guide further treatment options; treatment decisions often depend on severity of depression and degree of response to prior treatment
      • Options include increasing frequency of psychotherapy sessions, changing type of psychotherapy, optimizing dose of medication, and adding or changing medications (eg, trial of different selective serotonin reuptake inhibitor or serotonin and norepinephrine reuptake inhibitors instead of selective serotonin reuptake inhibitor)
    • Treatment options for severe disease refractory to psychotherapy and pharmacologic interventions: r20
      • Electroconvulsive therapy
        • Approved and effective treatment modality during pregnancy; risks of therapy must be weighed against risks of untreated illness r66
        • Consider for patients with severe depression, affective psychosis, and/or catatonia r15
      • Repetitive transcranial magnetic stimulation
        • Emerging treatment option; data on pregnant patients are limited r67
        • May offer a medication-free treatment option for some females with severe disease refractory to other treatment

    Maintenance pharmacotherapy for females treated for depression before pregnancy

    • Management of psychotropic medication use during pregnancy must balance the risk of adverse effects with the risk of untreated illness r45
    • No currently available antidepressants are absolutely contraindicated during pregnancy;r20 however, no psychotropic medication is approved by FDA for use during pregnancy r10
      • Note: monoamine oxidase inhibitors are discouraged during pregnancy owing to risk of hypertensive crisis when combined with tocolytics
      • Atypical antipsychotic medications are associated with heart and gastrointestinal defects, cleft palate when used in early pregnancy r68
      • Valproate is a known teratogen and use as a psychotropic medication is discouraged in patients with childbearing potential r20r49
    • Continue current antidepressant that is successfully managing symptoms, particularly for females with a history of severe or recurrent depression and history of relapse when discontinuing maintenance medication, even if asymptomatic at the time of conception r4
    • Discontinuing antidepressants during pregnancy is generally not recommended r7r20
      • Discontinuation of antidepressants is associated with high relapse rates of major depressive disorder. However, relapse may occur despite ongoing medication therapy r7
      • May consider discontinuing ongoing pharmacologic therapy during pregnancy for select patients with mild depression. For these patients, gradually taper antidepressant over 1 to 2 weeks with close support and monitoring from a psychotherapist or psychiatrist r56
      • Before pregnancy is the ideal time to consider careful selective serotonin reuptake inhibitor taper for appropriate patients (ie, patients with mild and stable depression without a history of recent relapse or several depressive episodesr17) with the intent to avoid fetal medication exposure r45

    Drug therapy

    • Selective serotonin reuptake inhibitors r69c158
      • Citalopram c159
        • Citalopram Hydrobromide Oral tablet; Adults 18 to 60 years: 20 mg PO once daily, initially. May increase the dose at intervals of at least 1 week if inadequate response and depending on tolerability. Max: 40 mg/day. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
      • Sertraline r70c160
        • Sertraline Hydrochloride Oral tablet; Adults: 50 mg PO once daily, initially. May increase the dose by 25 to 50 mg/day at intervals of at least 1 week if inadequate response and depending on tolerability. Usual dose: 50 to 200 mg/day. Max: 200 mg/day.
          • Note: sertraline oral solution contains 12% alcohol and is not recommended during pregnancy because there is no known safe level of alcohol exposure during pregnancy. Use other sertraline formulations during pregnancy only if the potential benefit to the mother outweighs the potential risk to the fetus
      • Escitalopram r71c161c162
        • Escitalopram Oral tablet; Adults: 10 mg PO once daily, initially. May increase the dose to 20 mg/day after at least 1 week if inadequate response and depending on tolerability. Usual dose: 10 mg/day. Max: 20 mg/day.
      • Fluoxetine c163
        • Fluoxetine Hydrochloride Oral tablet [Depression/Mood Disorders]; Adults: 20 mg PO once daily, initially. May increase the dose after several weeks if inadequate response and depending on tolerability. May divide doses of 20 mg/day or more in 2 doses. Max: 80 mg/day.
    • Serotonin-norepinephrine reuptake inhibitors c164
      • Duloxetine c165
        • Duloxetine Oral capsule, gastro-resistant pellets; Adults: 20 or 30 mg PO twice daily or 60 mg PO once daily, initially. Alternatively, 30 mg PO once daily for 1 week, then 60 mg PO once daily. Usual Max: 60 mg/day. Max: 120 mg/day.
      • Venlafaxine c166
        • Venlafaxine Hydrochloride Oral tablet, extended-release; Adults: 75 mg PO once daily, or alternatively, 37.5 mg PO once daily for 4 to 7 days, then 75 mg PO once daily, initially. May increase the dose by 75 mg/day at intervals of at least every 4 days if inadequate response and depending on tolerability. Max: 225 mg/day.
    • Noradrenergic and specific serotonin antidepressants c167
      • Mirtazapine r71c168
        • Mirtazapine Oral tablet; Adults: 15 mg PO once daily at bedtime, initially. May increase the dose up to 45 mg/day at intervals of at least 1 to 2 weeks if inadequate response. Max: 45 mg/day.
          • Safe use of mirtazapine during pregnancy has not been established. Therefore, it should not be administered to females of childbearing potential unless, in the opinion of the treating physician, the expected benefits to the patient outweigh the possible hazards to the fetus
    • Noradrenergic and dopaminergic antidepressants c169
      • Bupropion c170
        • Bupropion Hydrochloride Oral tablet, extended release 12 hour [Depression/Mood Disorders]; Adults: 150 mg PO once daily, initially. May increase the dose to 150 mg PO twice daily after 3 days, and then 200 mg PO twice daily after several weeks if inadequate response. Max: 400 mg/day.
    • Tricyclic antidepressants r69c171
      • Desipramine c172
        • Desipramine Hydrochloride Oral tablet; Adults: 100 to 200 mg/day PO once daily or in divided doses; start at lower dose and increase dose gradually as needed and tolerated. Max: 300 mg/day. Reduce dose to the lowest dose that will maintain remission after satisfactory improvement has occurred.
      • Nortriptyline c173
        • Nortriptyline Hydrochloride Oral capsule; Adults: 25 mg PO 3 or 4 times daily, or alternately, 75 to 100 mg PO once daily, initially; start at lower dose and increase dose gradually as needed and tolerated. Max: 150 mg/day. Reduce dose to the lowest dose that will maintain remission after satisfactory improvement has occurred.

    Nondrug and supportive care

    Nonpharmacologic psychotherapeutic treatment modalities

    • First-line modalitiesr52 include:
      • Cognitive behavioral therapy c174
        • Focus involves correction of negative thinking and associated behaviors r25
      • Interpersonal therapy c175
        • Focus includes attention to role transition, interpersonal functioning, and building social rapport r4r10
        • Structured, time-limited psychotherapy
    • Other psychotherapeutic options include:
      • Perinatal period-specific treatments: mindfulness-based intervention and perinatal dyadic psychotherapy r45c176c177
      • General treatment modalities for depression: behavioral activation therapy, problem-solving therapy, nondirective counseling, and psychodynamic therapy r35r72c178c179c180c181

    Anticipatory guidance and education c182c183

    • Educate patient and family about illness r4r15c184
    • Anticipate potential problems that may arise in postpartum period and develop coping strategies (eg, based on cognitive behavioral therapy or behavioral strategies) r35c185
    • Encourage open communication with medical professional(s): thoughts of self-harm, suicidal ideation, and homicidal ideation (eg, murder-suicide of mother and infant) c186c187
    • Maximize wellness strategies including: r45
      • Engage in appropriate exercise
      • Optimize sleep, particularly consecutive hours of undisrupted sleep
      • Optimize nutrition
      • Strengthen family and social support networks
      • Use stress-reduction techniques

    Adjunct measures that may be effective include:

    • Routine exercise and sleep regimen r73c188c189c190c191
    • Massage, yoga, and mindfulness techniques r4c192c193c194
    • Peer support and support groups for females who struggle with depression during pregnancy r15c195c196
    • Data are mixed regarding efficacy of other complementary treatments (eg, ω-3 fatty acids, folate, St John's wort, bright light therapy, acupuncture) r4r74c197
      • Bright light therapy may be helpful for patients with a seasonal component to their affective disorder r7r15r45c198
      • Acupuncture may be helpful for select patients r45c199
    Procedures
    Electroconvulsive therapy r75c200
    General explanation
    • Generalized seizures are intentionally induced using electrical impulses
    • Typically performed multiple times per week until clinical response is seen
    • Average course is 6 to 12 treatments, which are administered to patient who is under anesthesia and on muscle relaxants
    • Evidence of benefit in pregnancy is limited and derived from case reports and case series r7
    • Specific precautions for pregnant patients include: r4r52r53
      • Some anesthesiologists recommend intubation to protect the airway after the first trimester because there is increased risk of gastric reflux and aspiration during the second and third trimesters r15
      • Fetal heart rate monitoring before and after procedure is recommended r15
      • Obstetrician should be readily available during procedure in the event of fetal compromise r15
    Indication
    • May be used as first-line therapy for patients who have: r52
      • Psychotic depression r15
      • Catatonia r15
      • Severe suicidality
      • Depression posing serious risk to health of the patient or fetus r15
      • Previous positive response to this treatment method r15
      • Anorexia or rapidly deteriorating physical status
      • Treatment-resistant depression
      • Repeated medication intolerance
    Contraindications
    • There are no absolute contraindications in any trimester of pregnancy r7
    • Relative contraindications include:
      • Younger than 18 years
      • Space-occupying brain lesions
      • Elevated intracranial pressure
      • Recent myocardial infarction
      • History of retinal detachment
      • Pheochromocytoma
    Complications
    • Complications in the fetus include arrhythmia and demise; in the mother, vaginal bleeding, uterine contractions, and premature labor r4r20
    • General adverse complications include:
      • Transient postictal confusion and period of antegrade and retrograde memory loss
      • Transient rise in heart rate, cardiac workload, and blood pressure
      • Aspiration r15
      • Fractures
      • Dental and tongue injuries
    Repetitive transcranial magnetic stimulation r76c201
    General explanation
    • Involves applying a strong, pulsed magnetic field to targeted brain region (often dorsolateral prefrontal cortex region when treating for depression) r77
    • Electromagnetic coil is held against patient's forehead, and short electromagnetic pulses are administered through the coil to generate electromagnetic field r77
    • Electromagnetic field results in regional neuronal depolarization and generation of action potentials r77
    • Data support efficacy of various techniques (eg, high-frequency, low-frequency, theta burst pulse pattern) and application to various target areas for improvement in patients with pharmacoresistant depression r77
    • Treatment appears to decrease depression scores in peripartum depression r78
    • Treatments are repeated daily for 4 to 6 weeks; a typical session lasts 30 to 60 minutes and does not require anesthesia r79r80
    Indication
    • Patients with major depression recalcitrant to antidepressant drug therapy r48r52
    Contraindications
    • Absolute and very strong contraindications include:
      • Ferromagnetic metal in the head (eg, plates, pins, bullets, shrapnel, aneurysm clips)
      • Microprocessor implants in the neck (eg, vagal nerve simulator, deep brain stimulator)
      • Life-sustaining microprocessor implants anywhere in the body (eg, prosthetic cardiac valves)
    • Relative contraindications include:
      • Ferromagnetic material in the neck and chest
      • Microprocessor implants below the neck (eg, spinal pumps, stimulators)
      • Conditions that may lower seizure threshold (eg, brain lesion, major head trauma, medications, recent withdrawal from alcohol or benzodiazepines)
      • Hearing loss and tinnitus
    Complications r81
    • Tension-like headache
    • Localized application site discomfort or pain
    • Seizure during treatment; approximately 0.1% risk over the full course of treatments

    Comorbidities

    • Substance or alcohol use disorders c202c203
      • A significant proportion of pregnant females with a major depressive episode report either misusing opioids, using marijuana, or drinking alcohol r6
      • Treat substance use disorder while treating depression
    • Coexisting psychiatric conditions, such as anxiety, obsessive-compulsive disorder, and personality disorders c204c205c206c207
      • May affect the treatment of major depression and require additional treatment specific for comorbid disorder
      • Peripartum depression is comorbid with anxiety in approximately 28% of patients; effective treatment involves treating both depression and anxiety r5
      • Approximately 22% of patients with a positive perinatal depression screen will be found to have bipolar disorder if further evaluated; treatment with a mood stabilizer is usually indicated and antidepressant monotherapy is contraindicated r5
      • Referral to specialty psychiatric care is indicated patients with comorbid psychiatric conditions r49

    Monitoring

    • All patients with depressive disorders during pregnancy
      • At every clinical encounter, screen for threat of harm to self or others c208c209
      • Monitor clinical symptoms and assess for decline in function throughout pregnancy and postpartum period c210
      • Frequency of monitoring varies
        • Determine based on depression severity, presence of suicidal ideation, adherence to treatment, strength of social supports, and presence of coexisting medical conditions c211c212c213c214c215
        • During the initial phase of treatment, monitoring can vary from once a week to multiple times a week, depending on depression severity c216c217
    • Patients requiring psychotropic medication
      • Frequently monitor symptom control, particularly during the second and third trimesters r45c218
      • Patients often require their dosage of selective serotonin reuptake inhibitor to be increased during the latter stages of pregnancy owing to multiple pharmacologic changes in metabolism of the medication during the second and third trimesters r45c219c220c221
      • Adjust selective serotonin reuptake inhibitor dosing based on clinical symptom control r45c222
      • Consider fetal echocardiography with first-trimester paroxetine exposure r4r45c223
      • Venlafaxine is associated with dose-related increases in blood pressure; closely monitor blood pressure. Consider tapering and discontinuing if the patient develops preeclampsia r15c224
      • Therapeutic drug monitoring is recommended for certain psychotropic medications during both dose titration and maintenance therapy at least once per trimester and within 24 hours after delivery r82c225
        • Monitoring of tricyclic antidepressants is strongly recommended r82
    • Neonates exposed to selective serotonin reuptake inhibitor
      • Rigorous monitoring for poor neonatal adaptation syndrome is not standardized r17
      • Absence of manifestations by 72 hours indicates that poor neonatal adaptation syndrome is unlikely to develop r17c226

    Complications and Prognosis

    Complications

    • Complications secondary to untreated or undertreated prenatal depression include increased risk for the following: r7
      • Pregnancy-related complications and associations including: c227
        • Poor health behaviors leading to increased risk for obstetric complications and poor pregnancy outcomes r4c228c229
          • Poor patient adherence to prenatal care, prenatal vitamins, and prescribed medications c230
          • Smoking, alcohol consumption, and substance use
          • Poor nutrition leading to poor weight gain c231
          • Lack of exercise
        • Ambivalence about the pregnancy and decreased intention to breastfeed r4c232c233
        • Suicidal ideation r4c234
        • Suicide c235
          • Absolute risk is low; however, suicide does represent a leading cause of death in depressed pregnant females, particularly in association with untreated depression r83r84
        • Operative delivery requirement r85c236
        • Intrauterine growth restriction r85c237
        • Gestational diabetes
        • Preeclampsia
        • Preterm birth r4r85r86c238
        • Low-birthweight and small-for-gestational-age neonate r4r85c239c240
        • Postpartum depression r42c241
      • Effects on infant and child
        • Outcome data are mixed and difficult to separate from multiple potential confounding variables (eg, continued postnatal maternal depression and anxiety, paternal mood symptoms, postpartum caregiving, other environmental factors) r4
        • Potential complications include: r4c242
          • Neonate and infant: lower neonatal behavioral scores,r87 decreased vagal tone, diminished cortisol reactivity, reduced reactivity to pain or stress, depressed temperament, increased irritability, decreased attention, sleep problems, and delayed neuromotor and language developmentr45c243c244c245c246c247c248c249
          • Young child: internalizing behaviors, externalizing behaviors, fearful temperament, anxiety, and delayed motor and cognitive development c250c251c252c253c254c255
          • Older child: altered stress response, attention-deficit/hyperactivity disorder, depression, and anxiety disorders c256c257c258
    • Complications secondary to prenatal exposure to antidepressant medications include:
      • Poor neonatal adaptation syndrome (also called neonatal toxicity, neonatal behavioral syndrome,r4 postnatal adaptation syndrome) c259
        • Occurs in up to one-third of neonates exposed to selective serotonin reuptake inhibitors and other psychotropic medications (eg, serotonin and norepinephrine reuptake inhibitors) late in the third trimester r4
        • Manifestations may include respiratory distress r4r42r85
          • General: temperature instability, feeding difficulty, vomiting, sleep disturbance, jaundice, and hypoglycemia
          • Cardiovascular: prolonged QT interval and arrhythmias r10
          • Respiratory: respiratory distress, apnea, and cyanosis
          • Central nervous system: tremor, jitteriness, hypotonia, hypertonia, hyperreflexia, irritability, persistent crying, lethargy, and seizures
        • Manifestations are usually mild and transient; age at onset is usually birth to 3 days and manifestations usually resolve within a few days. Less typically, manifestations may persist from 2 weeks to 1 month r45r85
        • Most manifestations are mild and require only close observation and supportive care r42
        • Dose-dependent relationship with syndrome severity has been observed r85
      • Persistent pulmonary hypertension of the newborn c260
        • Failure of pulmonary vasculature to relax, which normally occurs during circulatory transition to postnatal life; results in extrapulmonary right to left shunting with potential cyanosis and respiratory distress r85
        • Data are conflicting; there may be small increased risk with exposure after 20 weeks of gestation (odds ratio, 1.28; 95% CI, 1.01-1.64),r88 but some studies have found no increased riskr42
      • Postpartum maternal hemorrhage c261
        • Exposure to selective serotonin reuptake inhibitors late in pregnancy may increase risk of postpartum bleeding, particularly upper gastrointestinal bleeding r45
        • Data are inconsistent and conflicting; reported relative risk is at best small (1.47; 95% CI, 1.33-1.62)r89
      • Validity of other possible suspected complications is unclear and debated
        • Data are conflicting and often inconclusive owing to inability to ethically conduct well-designed prospective studies. Available study designs are subject to multiple confounding variables (eg, uncontrolled underlying depression, poor prenatal health behaviors, concomitant medication, tobacco use, substance use, comorbid medical conditions [eg, obesity, diabetes, hypertension]) r4
        • May include possible small, but increased, risk of the following:
          • Minor congenital cardiac malformations may occur with first-trimester paroxetine exposure (eg, self-resolving septal defects) r4c262
            • Risk is about 1% (risk among general population of newborns is about 0.7%) r85
          • Preterm birth (modest effect, pregnancy shortened by 3-5 days) r4c263
          • Delayed motor development (mild and transientr45) r4r10c264c265
          • Lower birth weight (small effect, weight decreased by about 74 g) r4c266
          • Lower 1- and 5-minute Apgar scores (small effect, largely undetermined clinical significance) r4r17

    Prognosis

    • Untreated major depressive disorder in pregnancy poses a risk to both mother and fetus (eg, malnutrition, poor prenatal care, substance use, suicide attempt, self-inflicted injury)
      • It has been found that more than half of pregnant patients with a major depressive episode did not receive any mental health treatment, with financial concerns being the primary reason r6
    • There is a high risk of relapse after a depressive episode, especially in the first 6 months; risk declines with time in remission r53
      • Risk factors for relapse include:
        • Presence of residual symptoms
        • Higher number of previous episodes
        • Increasingly severe disease
        • Prolonged duration of disease
        • Higher degree of treatment resistance during the most recent episode

    Screening and Prevention

    Screening

    At-risk populations

    • All pregnant patients are at risk
    • Higher risk occurs among certain patients including:
      • Patients with history of depression
      • Adolescent patients
      • Patients with risk factors for depression (eg, intimate partner violence, low socioeconomic status, poor or absent social or relationship support, psychosocial stress, anxiety)

    Guidelines

    • US Preventive Services Task Force recommends screening all pregnant and postpartum adults and adolescents (aged 12 years and older) for depression r28r90c267
      • Screening helps ensure accurate diagnosis, effective treatment, and appropriate follow-up r28
    • Most guidelines endorse routine perinatal screening for depression r26
      • Optimum timing for perinatal screening is not rigorously standardized r91
    • American College of Obstetricians and Gynecologists recommends all pregnant patients be screened for depression at the initial prenatal visit, again later in pregnancy, and at postpartum visits using a validated, standardized tool r5
    • American Psychiatric Association recommends screening with a validated screening tool twice during pregnancy (once in early pregnancy to assess for preexisting psychiatric disorders and once later) as well as postpartum screening during pediatric visits throughout the first 6 months postpartum r92
    • Australian guidelines recommend screening for depression at least once during pregnancy and once in the postpartum period r93
    • Canadian guidelines do not endorse routine questionnaire-based screening for depression for all patients during pregnancy and in the postpartum period r94r95r96

    Screening tests

    • Standardized depression screening tools: r26r27r28r35r90
      • Perinatal screening tools: Edinburgh Postnatal Depression Scale,r1Patient Health Questionnaire-9,r2 and Postpartum Depression Screening Scaler3c268c269c270
      • General screening tools: Beck Depression Inventory, Major Depression Inventory, and Hamilton Depression Rating Scale c271c272c273
    • Short case-finding questions (2 or 3 questions) are advocated by some guidelines to identify females who need to be monitored closely for depression and further assessed with standardized screening tools r26r97
      • Questions are as follows:
        • During the past month, have you often been bothered by feeling down, depressed, or hopeless?
        • During the past month, have you often been bothered by little interest in pleasure or doing things?
      • If either response is yes (affirmative), then follow with the following third question:
        • Is this something you feel you need or want help with?
      • Rigorous validation is lacking; however, data show that negative predictive values for excluding depression approach 100% r26

    Prevention

    • Data are scarce regarding prevention strategies for depressive disorders in pregnancy r17r34r98
      • Psychosocial and psychological interventions (eg, intensive, professional-based postpartum home visits; telephone-based peer support; interpersonal psychotherapy) have been shown to result in fewer diagnoses of postpartum depression r99
    • Effective preconception planning may diminish risk of active disease or relapse of known depression during pregnancy r15
      • Encourage the patient to review risks of untreated disease and medication use during pregnancy before conception
      • Establish an appropriate psychotropic medication regimen for depressed females of childbearing age
      • Encourage clinically unstable patients to consider deferring pregnancy until clinical stability is achieved
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