Depression in Pregnancy

January 4, 2008

Depression is the most common psychiatric disorder, so it's a commonly encountered pre-existing condition during pregnancy. Additionally, women have it twice as often as men, and among women, there is an increased tendency toward it during the reproductive years. Where the menstrual cycle fits in as a contributing factor is unknown, as we've still only just scratched the surface of the whole PMS mystery. Certainly borderline depression can be affected by the hormonal impact of the menstrual cycle.

And by pregnancy, too.

Pregnancy Depression

Pregnancy is a particularly fertile field for depression to either start anew or worsen if already a problem. The extra physical, financial, marital, and sexual stresses come whether one is ready or not. On top of that, any new feelings of poor self-image can reinforce depression's already negative self-image problems.

An obstetrician is qualified to handle mild depression, anxiety, "the blues," and general moodiness. But severe depression is a very serious illness that requires the additional care of a psychiatrist, because many people die from it! I'm talking about suicide, so all moodiness should be questioned.

Diagnosing Depression in Pregnancy

Depression diagnosis can often be a confusing challenge. For instance, a common cause (co-illness?) of depression is thyroid disorder. Many women who have hypothyroidism will present first as a depressed patient, so thyroid function testing is a very good idea in anyone complaining of depression. Also, depression can be over-diagnosed. For instance, if a woman's husband has just died in a car crash, her house has burned down, and she's been mugged and beaten up recently, depression is probably not an illness but a reasonable reaction to these things.

The point of this ridiculous example is that it's not inappropriate to be bummed out over really bad things in one's life. Clinical depression, on the other hand, is when there is an inappropriate reaction to things, known or unknown.

 

Predisposing factors that make depression more likely are:

 

  • Childhood trauma, like death or illness of a parent or sibling
  • Childhood sexual abuse, which will distort the well-being of a person on many levels
  • Family history of depression
  • Lower socioeconomic status (translated, poverty)
  • Stress
  • Substance abuse

 

 

In any new depression during or after the pregnancy, it's important to tell the difference between merely "feeling depressed" and clinical depression. Feeling Depressed

Postpartum Depression

After delivery, feeling depressed may respond to an understanding ear and a reassurance that this is common. What a new mother (and father) fail to anticipate is a selfish inner rebellion to the fact that they've been pushed to the #2 (or #3) position in the family and can't just do whatever they want anymore. For instance, let's take movies. As a couple you pretty much see all of the movies you really want to see either at the theater or on cable or tape. Along comes baby.
Forget movies. No movies for about two years! And this is a colossal drag since life has been one big date up till now. Now, you can even forget seeing a movie at home uninterrupted by feedings or diapers or just checking on a suspiciously quiet baby. And if you go someplace, no more just hopping into the car and goin'. You've got to haul all of this stuff along: packages of diapers, wipes, blankets, clicky toys, and the like. And as the baby gets older, add to this haul of paraphernalia collapsible rolling pods, strollers (two varieties the deluxe and the umbrellas), medicines, and snap containers of gruel.

It won't get any better until you realize and accept the new world order:

You just have to put your life on hold for a couple of years.

On the surface, this is a bitter disappointment to your own inner child who wants to shuck & jive and rock & roll; but your thinking parental brain knows better--you are now a family and you're doing this for your children. Fulfillment in life trust me is much better than just having a lifetime of fun.

During pregnancy, feeling depressed is usually a problem in which a woman, once feeling fit, experiences nagging physical complaints caused by something she has no control over. As a woman's abdomen expands in the mirror, this physical sign is symbolic of a shift from seeing herself as a woman to seeing herself as a mother. From seeing herself as a sexual being to seeing herself as a maternal one.

"What have I gotten myself into?" isn't a question with a remedy, unfortunately, except for the cruel, "Deal with it." And because, I'm told, men are from Mars, they're often not the most sympathetic persons and often fail to come through. However, a couple who are pregnant for all of the right reasons or who have put themselves into the big picture of what pregnancy is all about will ultimately find a way to stay afloat on this endless sea of uncertainty. It's a "sea-legs" sort of thing and a matter of self-perspective. If the relationship between the expectant parents is good, mild depression need only be a temporary reaction to a permanent change in one's life.

 

Clinical Depression in Pregnancy

Alterations in thinking, delusions, or hallucinations, however, push the diagnosis of depression, categorically, into a psychosis. After delivery, postpartum depression is a serious illness to be distinguished from the "postpartum blues." Thought disorder can get fairly creepy in that the mother starts having threatening thoughts about the baby. But a woman so afflicted isn't any more afflicted after birth than she would be any other time if she's got a history of mood disorders. According

to the American College of Obstetricians and Gynecologists, Technical Bulletin 182, "Depression in Women,"

"Major clinical depression has been thought to be more common following childbirth than during other periods of a woman's life. However, current studies do not substantiate this belief. Women at risk for significant postpartum depression are more likely to have a family history of depression, a previous postpartum depression, or significant adjustment problems with childbirth. It has been demonstrated that women who have a planned pregnancy in a secure environment, enjoy a supportive relationship with their partner, and have manageable levels of life stress are less likely to experience postpartum depression."

 

And to her marriage. Often a new father, dealing with issues of the new world order himself, won't understand why such a wonderful time is being ruined by a bad mood, an attitude, or anger misdirected at the most likely victim in this drive-by shooting: him! Obstetricians, nurses, social workers, midwives, doulas even lactation nurses can be a crucial help in recognizing depression and counseling a husband on the pathology involved and how this illness needs as much patience as convalescence from any physical illness.

During pregnancy, real depression is a high risk situation which tends to make patients prone to non-compliance with their prenatal care (keeping appointments, eating right, doing what's best for the baby). Substance abuse, either prompting the depression or because of it, doesn't mix well with a developing baby. The legitimate drugs for depression are also a concern, but they are weighed as a risk vs. benefit decision. But in true depression, the benefit usually far outweighs any potential risks.

The woman who is doing fine on today's anti-depressants but then gets pregnant will have worries over what a particular medicine might do to her baby. Luckily, there's been an explosion of effective and for the most part safe antidepressant drugs over the last fifteen years, and most of these patients will be on the newer, modern drugs. The seriously depressed patient may still present on the older stuff, however, and a switch to a safer medicine may present risks of worsening her condition.

DRUGS FOR DEPRESSION DURING PREGNANCY
(The American Academy of Pediatrics feels the permanent effects of antidepressants on the nursing infant to be unknown and therefore doesn't officially sanction their safety at this time.)

Review the FDA Classes of Drug Risks in Pregnancy

Below is a simple review of drugs used for both clinical depression and the simpler mood disorder of "feeling depressed."

 

 

The New Stuff
The "selective serotonin re-uptake inhibitors" (SSRIs)

 

These drugs keep the levels of serotonin higher in the brain. Serotonin is a neurotransmitter that rises and falls, affecting mood and well-being. These medicines decrease the amount of serotonin that is reabsorbed, keeping the levels higher and constant.
Zoloft (sertraline ) FDA Class B. Probably safe.
Prozac (fluoxetine) FDA Class B. Probably safe. There's more data on
Prozac than Zoloft, prompting one to think that Prozac may be safer.
But it's just that there's more data exonerating the Prozac .
Paxil (Paroxetine) FDA Class D. Not recommended as there is evidence of fetal harm.
Luvox (fluvoxamine) FDA Class B. Probably safe. This drug not only keeps levels of serotonin up, but also decreases the re-uptake of dopamine, another "feel good" neurotransmitter. In fact, dopamine is the neurotransmitter that is especially high in addictions, and its fall is associated with the unpleasant physical suffering called withdrawal. This is the whole idea behind using Wellbutrin (aka, Zyban) (a dopamine re-uptake inhibitor) to quit smoking (see next line).
Wellbutrin, Zyban (Bupropion) FDA Class B. Probably safe, and in fact it's safety has been well-established in that there haven't been any reports of problems with it.
Effexor (venlafaxine). FDA Class B. Probably safe. This drug's actual mechanism is unknown, but it works probably by increasing the neurotransmitter activity as well. There have been some concerns regarding an increase in blood pressure with Effexor, and this side effect would be particularly confusing in a pregnancy because of the usual vigilance for Pregnancy-induced Hypertension (PIH, formerly called "toxemia" or "pre-eclampsia").

Anti-anxiety Agents

Buspar (buspirone) FDA Class B. Probably safe. As described above, this decreases the re-uptake of dopamine.
Atarax (or Vistaril) (Hydroxyzine) FDA Class C. There's a small possibility of abnormalities if given during the first trimester. But Vistaril is a popular anti-nausea drug that is used commonly during pregnancy. In my practice, I will just try to avoid it during the first trimester, and I don't generally use this as a first choice for anxietyuspar being a better choice.
Xanax FDA Class D. See below, "The bad guys in pregnancy."
Review the FDA Classes of Drug Risks in Pregnancy

 

 

The Bad Guys in Pregnancy

Valium (diazepam) FDA Class D. Not recommended. Quick to reach the fetus, but slow to clear, this drug has been associated with facial development abnormalities, cleft lips and palates, growth retardation...Do I need to go on? These warnings are for the chronic use or abuse of Valium. (Using it acutely in a seizure situation probably doesn't have the same dangersot to mention that using it for dire emergencies is better than not using it.)
Xanax (Alprazolam) FDA Class D. Not recommended. This drug is related to Valium and all of the above apply. In my practice, I've found it more addictive than the serotonin-re-uptake inhibitors. (Actually, I've never had trouble getting patients off of the serotonin-re-uptake inhibitors; but I can't say the same for Xanax. Of
course, in all fairness to Xanax, it's probably used most frequently against labeling instructions.)
Dalmane (Alprazolam) FDA Class D. Same story, it's an "-azepam" drug. In fact, it's a good idea to stay away from any drug whose generic name ends in "-azepam." Dalmane is usually used as a sleeping pill. Withdrawal in newborns is always a possibility with the "-azepams."
Ativan (lorazepam) Lorazepam is a benzodiazepine. Lump it in with the above "bad guys."
Tranxene (chlorazepate) also an "-azepam," actually, a "-diazepine". Stay away from it, too.
Review the FDA Classes of Drug Risks in Pregnancy

 

 

The Older Depression Drugs

Elavil (amitriptyline) FDA Class D. Probably safe, but it earns the "D" status because there have been rare reports of deformities. "Safe for most pregnancies" doesn't reassure the one person whose baby is affected adversely.
Tofranil (Imipramine) FDA Class D. Same story as Elavil. Also, one mustn't forget the withdrawal a newborn may suffer at the hands of these drugs.
Review the FDA Classes of Drug Risks in Pregnancy

 

 

In The Real World--Are Depression Drugs Safe In Pregnancy

So in a typical ObGyn practice, what's typical? The SSRIs are so safe, it seems, that I'll use them (especially Wellbutrin and Prozac) during the 2nd and 3rd trimesters even for mild depression if the depression is interfering with a patient's happiness. I won't venture so casually into the 1st trimester unless the depression is severe. If severe depression involves any type of thought disorder, I'll insist that a psychiatrist be involved.

Breastfeeding risks of using depression drugs should be left to the Pediatrician. If the benefit of the drug during breastfeeding outweighs the risk, still the new mother may want to switch to formula so that she can treat herself without worry.

Outside of pregnancy and breastfeeding, I feel that the SSRIs are a very safe drug class and use them for anything from PMS (now melodramatized as "premenstrual mood dysphoria") to depression. Interestingly, Prozac is now available as Sarafem for PMS the subject of another article.

For just anxiety in the non-pregnant woman (without depression), I prefer Buspar or the newer Celexa, and I don't usually use Xanax, Valium, or the diazepam class. This is because anxiety tends to be a long term problem, and the diazepam class is not a safe long term drug because of the addictive potential.

 

Plot Thickens--Treating Depression in Pregnancy

The neurotransmitter aspect of treating disorders is all the rage in pharmaceutical research. Just take serotonin, for instance. There are some serotonin receptors that affect mood, some that affect appetite (the SSRI Meridea is used in dieting), and other receptors that do other things. The SSRIs hint at an exciting growth direction for drugs for many diseases. True, we've had our disasters (the Redux fiasco years ago which resulted in heart damage), but for the most part this direction has yielded many safe drugs that seem to have minimum risk in pregnancy.

That's good news, because pregnant people get sick, too.

 

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