The Importance of Managing Psychiatric Disorders During Pregnancy and Postpartum

CONFERENCE REPORTER

“We always want to make sure we weigh the risks of the untreated psychiatric disorder when we are considering treatments, especially medication exposures, for women of reproductive age,” said Marlene Freeman, MD, professor of psychiatry at Harvard Medical School.

In her presentation, “Pregnancy and Postpartum Management of Psychiatric Disorders,” at the 2022 Annual Psychiatric Times™ World CME Conference in San Diego, Freeman discussed how it is important to focus on antidepressant treatment in women with depression during pregnancy and the postpartum period. Approximately 45% of pregnancies in developed countries are unplanned, shared Freeman, and 75% of teen pregnancies are unplanned.¹ Furthermore, 82% of US women have had a child by age 40.¹ This is why it is important to tend to psychiatric disorders, which carry risks for both mother and baby if left untreated.

“The risks of the untreated psychiatric disorders impact efficacy and outcomes as well as child development overall,” Freeman said.

Freeman also stated that the absolute risk of selective serotonin reuptake inhibitors (SSRIs) exposure in pregnancy is small, and reproductive safety data on SSRIs exceed what is known about many other medications used in pregnancy. Prevalence of SSRI use during pregnancy is 3% to 7%.^2-7 

Antidepressant Use and Risk

According to recent research, there is no evidence of increased risk for major malformations or cardiovascular malformations in the offspring of women who took SSRIs while pregnant.⁸

Another concern raised about SSRIs there is the potential increased risk of autism. Freeman shared that, through studies and meta-analyses, results have determined that SSRIs are associated with increased risk of autism, but not by cause and effect because you must factor in maternal psychiatric illness, which appears to be the driving factor.⁹

Treatment Recommendations for Postpartum Depression

Approximately 10% to 15% of women experience major depressive episodes post-delivery, and that number increases to 25% to 40% if the woman has a history of major depressive disorder.

“Postpartum depression has been called the most common obstetrical complication,” Freeman said.

Freeman had a number of tips for treating mothers with postpartum depression, including using the lowest effective doses of SSRIs, consulting with perinatal/reproductive psychiatry specialists as needed, and maximizing nonmedication treatments. These nonpharmacologic strategies are (1) maximized social supports, (2) psychoeducation of patient and family, (3) group therapy or support groups, (4) interpersonal therapy, and (5) cognitive behavioral therapy.^10-12

Concluding Thoughts

“There are a lot of unknowns involved with pregnancy,” Freeman concluded. “We want to make sure that the treatment decisions we make are really collaborative with patients.”

To further support patients and their clinicians, Freeman referred to www.womensmentalhealth.org as a good source of information.

References

1. Louik C, Lin AE, Werler MM, et al. First-trimester use of selective serotonin-reuptake inhibitors and the risk of birth defects. N Engl J Med. 2007;356(26):2675-2683.

2. Einarson TR, Einarson A. Newer antidepressants in pregnancy and rates of major malformations: a meta-analysis of prospective comparative studies. Pharmacoepidemiol Drug Saf. 2005;14(12):823-827.

3. Einarson A, Pistelli A, DeSantis M, et al. Evaluation of the risk of congenital cardiovascular defects associated with use of paroxetine during pregnancy. Am J Psychiatry. 2008;165(6):749-752.

4. Alwan S, Reefhuis J, Rasmussen SA, et al. Use of selective serotonin-reuptake inhibitors in pregnancy and the risk of birth defects. N Engl J Med. 2007;356(26):2684-2692.

5. Greene MF. Teratogenicity of SSRIs--serious concern or much ado about little? N Engl J Med. 2007;356(26):2732-2733.

6. Hallberg P, Sjoblom V. The use of selective serotonin reuptake inhibitors during pregnancy and breast-feeding: a review and clinical aspects. J Clin Psychopharmacol. 2005;25(1):59-73.

7. Wogelius P, Nørgaard M, Gislum M, et al. Maternal use of selective serotonin reuptake inhibitors and risk of congenital malformations. Epidemiology. 2006;17(6):701-714.

8. Huybrechts KF, Palmsten K, Avorn J, et al. Antidepressant use in pregnancy and the risk of cardiac defects. N Engl J Med. 2014;370(25):2397-2407.

9. Andrade C. Antidepressant exposure during pregnancy and risk of autism in the offspring, 1: meta-review of meta-analyses. J Clin Psychiatry. 2017;78(8):e1047-e1051.

10. Cohen LS, Wang B, Nonacs R, et al. Treatment of mood disorders during pregnancy and postpartum. Psychiatr Clin North Am. 2010;33(2):273-293.

11. Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. Am J Obstet Gynecol. 2009;200(4):357-364.

12. Branquinho M, de la Fe Rodriguez-Muñoz M, Maia BR, et al. Effectiveness of psychological interventions in the treatment of perinatal depression: a systematic review of systematic reviews and meta-analyses. J Affect Disord. 2021;291:294-306.