What is the best approach for management of depression in a pregnant woman after a suicide attempt?

March 1, 2007

Although suicidal ideation occurs in roughly 5% to 14% of pregnancies,1 suicide attempts are relatively rare (0.04%) and are associated with substance abuse and poor pregnancy outcome.2 After a suicide attempt, the clinician must first consider the possibility of recurrence of self-destructive behavior by assessing the woman's motivation, her attitude toward the pregnancy, and the severity of her depressive symptoms.

Emergency physician

Bismarck, ND

Although suicidal ideation occurs in roughly 5% to 14% of pregnancies,1 suicide attempts are relatively rare (0.04%) and are associated with substance abuse and poor pregnancy outcome.2 After a suicide attempt, the clinician must first consider the possibility of recurrence of self-destructive behavior by assessing the woman's motivation, her attitude toward the pregnancy, and the severity of her depressive symptoms.

The quality of a pregnant woman's social support is critical. Someone who is either isolated or in conflict with an intimate partner, family members, or friends requires special attention. In particular, the clinician must screen for domestic abuse, which increases in pregnancy3 and correlates highly with suicidal behavior in women.4

It is also important to screen for alcohol or illicit drug use.2 Although many women reduce their use of addictive substances during pregnancy, some cannot. In certain jurisdictions, seeking help exposes a pregnant addict to the risk of being arrested for child endangerment--a Catch-22 that may precipitate suicidal acts. The Edinburgh Postnatal Depression Scale may help with the assessment of depressive symptom severity. This scale has been validated during pregnancy5 and controls for the overlap of symptoms of pregnancy and depression (especially fatigue and insomnia). The decision to recommend inpatient care or intensive or urgent but routine outpatient care depends on the initial risk assessment.

If a pregnant woman meets criteria for major depression and plans to continue the pregnancy, her depression should be managed the same way as that of a nonpregnant patient. Interpersonal or cognitive behavioral therapy may be sufficient for mildly to moderately depressed patients.6 The risks of using any conventional antidepressant during pregnancy are probably outweighed by the benefit of protecting the fetus from the risks of untreated depression. However, the nature of these risks is known only from anecdotal data about uncontrolled exposure and animal research.7 The older the drug, the more data are available.

The risks of antidepressant use during pregnancy, which are incalculably small, vary by trimester. The danger of fetal malformations ends with the first trimester. Immediately before delivery, maternal medication use may lead to withdrawal in the neonate. This can be managed symptomatically and should not lead to a tapering or lowering of dose before delivery. The SSRIs (especially paroxetine) increase the risk of a still rare complication: fetal pulmonary hypertension.8 Bupropion has the highest FDA safety rating in pregnancy, but this rating confers no substantial advantage for using bupropion over other antidepressant drugs.

Anticonvulsants and lithium pose serious fetal risks during pregnancy, and their use should be avoided, minimized, or closely monitored.7 Electroconvulsive therapy (ECT) is arguably the safest and most rapidly effective therapy for depression in pregnant women.9 In ECT, fetal exposure to medication is brief, the mother is hyperoxygenated, and women are positioned to maximize fetal blood flow and can be monitored for uterine activity during the procedure. Women with depression who are fearful of taking medication while pregnant, those with psychotic features, and those with severe depression or very high suicidal risk are candidates for ECT.

Julia Frank, MD

Associate Professor of Psychiatry

The George Washington University

School of Medicine and Health Sciences

Washington, DC

References:

REFERENCES

1. Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum.

Arch Womens Ment Health.

2005;8:77-87.2. Gandhi SG, Gilbert WM, McElvy SS, et al. Maternal and neonatal outcomes after attempted suicide.

Obstet Gynecol

. 2006;107:984-990.3. Naumann P, Langford D, Torres S, et al. Women battering in primary care practice.

Fam Pract.

1999; 16:343-352.4. Frank JB, Rodowski MF. Review of psychological issues in victims of domestic violence seen in emergency settings.

Emerg Med Clin North Am.

1999;17:657-677, vii.5. Heron J, O'Connor TG, Evans J, et al; ALSPAC Study Team. The course of anxiety and depression through pregnancy and the postpartum in a community sample.

J Affect Disord.

2004;80:65-73.6. Elkin I, Shea MT, Watkins JT, et al. National Institute of Mental Health Treatment of Depression Collaborative Research Program. General effectiveness of treatments.

Arch Gen Psychiatry.

1989;46:971-982.7. Jain AE, Lacy T. Psychotropic drugs in pregnancy and lactation.

J Psychiatr Pract.

2005;11:177-191.8. Chambers CD, Hernandez-Diaz S, Van Marter LJ, et al. Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn.

N Engl J Med.

2006;354:579-587.9. Rabheru K. The use of electroconvulsive therapy in special patient populations.

Can J Psychiatry.

2001;46:710-719.