Depression in pregnancy
Depression is one of the most common mental health conditions experienced by individuals worldwide. Unfortunately, the onset of pregnancy can trigger or exacerbate depression. Criteria for the diagnosis of depression are the same regardless of pregnancy status; however, depression is often overlooked in pregnancy, as the symptoms of depression are often similar to the somatic experiences associated with pregnancy. Fortunately, expectant mothers need not suffer from this condition: Depression is treatable during pregnancy, with psychotherapy and antidepressant medication whenever necessary. Although avoiding the use of medication during pregnancy is preferable, the benefits of prompt medical treatment of major depressive disorder may often outweigh the risks of exposure of the fetus to an antidepressant (Muzik & Hamilton, 2016).
FDA-approved drug, off-label drug, and nonpharmacological intervention for treating depression in pregnant women.
Pharmacologic treatment options should be seriously considered in women who are struggling with moderate to severe symptoms of depression, especially if the patient’s ability to function and care for herself is compromised. A decision to use antidepressants during pregnancy, in addition to counseling, is based on the balance between risks and benefits (Muzik & Hamilton, 2016). The biggest concern is typically the risk of birth defects from exposure to antidepressants. Overall, the risk of birth defects and other problems for babies of mothers who take antidepressants during pregnancy is very low. Antidepressant medications can be safely utilized in the treatment of depression in pregnant women (Reefhuis, Devine, Friedman, Louik, Honein, 2015). Currently, the first-line medication treatment for depressive disorders is one of the serotonin reuptake inhibitors (SSRIs), which have fewer side effects and are considered to be safer and more effective than the earliest antidepressants (Creeley & Denton, 2019). Among the 5 FDA-approved SSRIs medications for depression in pregnancy, my recommendation will be Sertraline (Zolof). Trazodone will be my choice of off-label medication and psychotherapy will be my choice of nonpharmacological intervention.
Risk and benefits of Zoloft and Trazodone in treating depression in pregnancy
According to a study by Bérard et al., (2015) among the 18,493 eligible pregnancies, 366 were exposed to sertraline, 1963 to other SSRIs, and 1296 to non-SSRI antidepressants during the first trimester of pregnancy. Sertraline use was not statistically significantly associated with the risk of overall major malformations when compared to nonuse of antidepressants. CDC, study data stated Sertraline (Zoloft) is among the safest antidepressants used during pregnancy. The study found that despite a slightly increased risk of certain birth defects from some SSRIs (paroxetine or fluoxetine), the actual risk among babies born to women taking one of these antidepressants is still very low (CDC, 2012). Having major depression during pregnancy is associated with an increased risk of premature birth, low birth weight, decreased fetal growth, and other problems for the baby. Unstable depression during pregnancy also increases the risk of postpartum depression and difficulty bonding with the baby. Potential complications/risks include maternal weight changes and premature birth.
A recent meta-analysis of sleep quality during pregnancy verified that problems with sleep are common during pregnancy, and also found that sleep quality may decline in the third trimester (Sedov, Cameron, Madigan & Tomfohr-Madsen, 2018). Pregnancy-associated sleep deprivation comorbid with insomnia related to depression is a situation that must be addressed as serious sleep problems are associated with an increased likelihood of preterm birth, longer labor, cesarean delivery, and prenatal and postpartum depression (Sedov et al., 2018). Trazodone will be an off-label medication of choice that will be safely prescribed to treat pregnancy/depression-induced insomnia. Trazodone can also be used as a single agent therapy for both depression and insomnia in pregnancy. A study by Einarson et al., (2016) concluded that trazodone during pregnancy is not associated with an increased risk for major fetal malformations. Trazodone is helpful at low doses for primary and secondary insomnia. Additionally, it is less expensive than some newer insomnia medications due to its general availability. The risk of teratogenicity, serotonin withdrawal syndrome is not expected based on human data (Einarson et al., 2016). Just like any SSRI, the risk of neonatal withdrawal sx or serotonin syndrome is possible.
Medication is certainly not the only means of managing a mental illness. I will also advocate for appropriate nonpharmacological treatment for patients in the perinatal period. Nonpharmacological approaches with demonstrated efficacy in the perinatal period include interpersonal psychotherapy structured on reducing the associated symptoms as a treatment option (Branquinho, et al., 2021). Research indicates that it is more effective and adapted for pregnant women with moderate to acute anxiety and depression (Brandon, Crowley, Gordon & Girdler (2017).
Clinical practice guidelines
APA guidelines support psychotherapy as the first choice of therapy for pregnant women with mild depression (Yonkers, et al., 2019). A thorough history must be obtained. For women with mild to moderate depression without a history of recurrent or severe depression or women with depression related to specific adjustments or stressors, psychotherapy with a trained provider may be sufficient. However, if the woman’s history indicates a need for an antidepressant—because of symptom severity, illness recurrences, or lack of access to psychotherapy—then a thorough risk-benefit discussion of antidepressants in general and the specific medication, in particular, is warranted (Molenaar, Kamperman, Boyce & Bergink, 2018). Collaboration with the patient’s obstetrician, and even her pediatrician, may be especially helpful in supporting the mother—and the psychiatrist—in making an informed decision and following through on it. Working with the pregnant woman and her supports (including family and providers) to understand what is known, what is unknown, the risks and the benefits of the whole picture will lead to a truly informed decision that will allow the mother to feel that she has made the best choice for her situation.
Bérard, A., Zhao, J. P., & Sheehy, O. (2015). Sertraline uses during pregnancy and the risk of major malformations. American journal of obstetrics and gynecology, 212(6), 795.e1–795.e12. https://doi.org/10.1016/j.ajog.2015.01.034
Brandon, A. R., Crowley, S. K., Gordon, J. L., & Girdler, S. S. (2014). Nonpharmacologic treatments for depression related to reproductive events. Current Psychiatry Reports, 16(12), https://doi.org/10.1007/s11920-014-0526-0
Branquinho, M., de la Fe Rodriguez-Muñoz, M., Maia, B. R., Marques, M., Matos, M., Osma, J., Moreno-Peral, P., Conejo-Cerón, S., Fonseca, A., & Vousoura, E. (2021). Effectiveness of psychological interventions in the treatment of perinatal depression: A systematic review of systematic reviews and meta-analyses. Journal of Affective Disorders, 291, 294–306. https://doi.org/10.1016/j.jad.2021.05.010
Centers for Disease Control and Prevention. (2018). Key Findings—A Closer Look at the Link Between Specific SSRIs and Birth Defects. Retrieved from https://www.cdc.gov/pregnancy/meds/treatingfortwo/features/ssrisandbirthdefects.html
Creeley, C. E., & Denton, L. K. (2019). Use of Prescribed Psychotropics during Pregnancy: A Systematic Review of Pregnancy, Neonatal, and Childhood Outcomes. Brain sciences, 9(9), 235. https://doi.org/10.3390/brainsci9090235
Einarson, A., Bonari, L., Voyer-Lavigne, S., Addis, A., Matsui, D., Johnson, Y., & Koren, G. (2016). A multicentre prospective controlled study to determine the safety of trazodone and nefazodone use during pregnancy. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 48(2), 106–110. https://doi.org/10.1177/070674370304800207
Molenaar, N. M., Kamperman, A. M., Boyce, P., & Bergink, V. (2018). Guidelines on treatment of perinatal depression with antidepressants: An international review. The Australian and New Zealand journal of psychiatry, 52(4), 320–327. https://doi.org/10.1177/0004867418762057
Muzik, M., & Hamilton, S. E. (2016). Use of antidepressants during pregnancy?: what to consider when weighing treatment with antidepressants against untreated depression. Maternal Child Health Journal ;20(11):2268-79. doi: 10.1007/s10995-016-2038-5. PMID: 27461022.
Reefhuis J, Devine O, Friedman J M, Louik C, Honein M A. (2015). Specific SSRIs and birth defects: bayesian analysis to interpret new data in the context of previous reports British Medical Journal 2015; 351 :h3190 doi:10.1136/BMJ.h3190
Sedov, I.D., Cameron, E.E., Madigan, S., Tomfohr-Madsen, L.M. (2018). Sleep quality during pregnancy: A meta-analysis. Sleep Med. Rev. 2018;38:168–176. doi: 10.1016/j.smrv.2017.06.005
Yonkers, K. A., Wisner, K. L., Stewart, D. E., Oberlander, T. F., Dell, D. L., Stotland, N., Ramin, S., Chaudron, L., & Lockwood, C. (2019). The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstetrics and gynecology, 114(3), 703–713. https://doi.org/10.1097/AOG.0b013e3181ba0632
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