Pregnancy: Everyone is happy, but you are depressed

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Depression During Pregnancy

Out of every 10 women who are pregnant, one or two have symptoms of major depression. Women who have been depressed before are at higher risk.
Depression is a serious medical condition. It poses risks for the woman and her baby. But a range of treatments are available. These include counseling, psychotherapy, support groups, therapy with light, and medications.

It is usually best for a team of health care professionals to work with a pregnant woman who is depressed or who has a history of depression. Team members include:

The provider who is caring for her during her pregnancy
A mental health professional
The provider who will take care of the baby after birth
Together, the team and the woman decide what is best for her and her baby. The team can connect her to support groups, help her consider counseling and psychotherapy, and assess the need for light therapy or medication.

Often a pregnant woman wonders whether antidepressant drugs, such as Zoloft and Prozac, will harm her baby or herself. There are no simple answers. Each woman and her health care providers must work together to make the best decision for her and her baby. The drugs used to treat depression have both risks and benefits.

IMPORTANT: If you are taking an antidepressant and find that you are pregnant, do not stop taking your medication without first talking to your health provider. Call him or her as soon as you discover that you are expecting. It may be unhealthy to stop taking an antidepressant suddenly.

What Is Depression?
Depression is an illness that involves the body, mood and thought. It affects the way a woman feels about herself and the way she thinks about things. This article addresses two types of depression:

Major depression: This serious illness interferes with a person's ability to work, study, sleep, eat and enjoy oneself. It may appear once in a person's life, but more often occurs several times.

Dysthymia: This is a less severe type of depression. Persons with this illness have long-term symptoms. They are able to conduct day-to-day activities, but they don't always function well or feel good. They may also have episodes of major depression.

Depression carries serious risks for the pregnant woman and her baby. These risks include:

Poor weight gain
Use of drugs or alcohol to self-medicate
Suicide
Depressed mothers are often less able to care for themselves or their children, or to bond with their children.

What Are the Symptoms of Depression?
A woman who is depressed feels sad or “blue” and has other symptoms that last for two weeks or longer. The other symptoms include the following:

Trouble sleeping
Sleeping too much
Lack of interest
Feelings of guilt
Loss of energy
Difficulty concentrating
Changes in appetite
Restlessness, agitation or slowed movement
Thoughts or ideas about suicide
Things other than depression can cause some of these symptoms. For instance, changes in appetite and trouble sleeping are common in pregnancy. Some medical conditions, such as anemia and hypothyroidism, can cause a pregnant woman to lack energy.

If you have any of these symptoms, talk to your health care provider. He or she will check to see what might be causing your symptoms. You need to be checked for depression if symptoms continue and interfere with your daily life and if your provider rules out other medical conditions.

Treatments
Depression can be treated in several ways. Support groups may help. Some women go to therapy or counseling with a mental health professional (such as a social worker psychotherapist or psychiatrist).

Some people suffer from a type of depression that comes on during the fall or winter, when there is less sunlight. This is called seasonal affective disorder (SAD). This condition is treated with light therapy. In her home, the patient looks into a box with special light bulbs. To avoid injury to her eyes, she looks at the lights indirectly. Typically, the patient does this from 15 minutes to two hours every day. The health provider may recommend a different number of minutes over time.

Mental health professionals often talk with women about the risks and benefits of antidepressants.

Two Groups of Antidepressants
Most antidepressants can be categorized into one of two groups.

Group 1: Selective serotonin uptake inhibitors (SSRIs). This group of drugs includes:

Prozac (fluoxetine)
Lexapro (escitalopram)
Zoloft (sertraline)
Celexa (citalopram)
Effexor (venlafaxine)
Paxil (paroxetine)
Cymbalta (duloxetine)
Group 2: Tricyclic antidepressants (TCAs). This group of drugs includes:

Elavil (amitriptyline)
Tofranil (imipramine)
Pamelor (Aventyl, nortriptyline)
Like many drugs, antidepressants can have side effects. SSRIs usually have fewer side effects than TCAs. Women differ in the type and seriousness of the side effects that they have.

What Research Tells Us About Antidepressants
It's challenging to study and understand the risks of any drug given to pregnant women. During pregnancy, two patients—the mother and the fetus—are exposed to the drug. Medications that are safe for a woman are sometimes risky for a fetus. Because of this, researchers have not studied many drugs during pregnancy.

Medical experts get most of their information about antidepressants during pregnancy by:

Drawing on research about drugs that have been approved for women who aren't pregnant
Conducting studies on animals
Studying women who took antidepressants before they knew they were pregnant
Several drugs have been used for many years without any obvious signs of serious risk to the baby. But some researchers have reported that some antidepressants may have increased risks. SSRIs are a newer group of drugs than TCAs. Researchers are continuing to study them.

Research has clearly shown that women who are not pregnant and are depressed are very likely to become ill again if they stop taking their medications. But we have less information about whether this is also true for pregnant women.

Here are some other things that research has told us.

One study in 2006 found that pregnant women with major depression are very likely to become ill again during their pregnancy if they stop taking their medication. A depressed woman may have trouble taking care of herself during pregnancy. This could threaten the health of the fetus.
Many studies have found no link between antidepressants and serious malformations in newborns. But in 2005, the U.S. Food and Drug Administration (FDA) issued a warning about Paxil (paroxetine) based on several studies. The warning said that taking the drug during the first three months of pregnancy may increase the risk of birth defects, particularly heart defects. Scientists do not yet know enough to draw a firm conclusion. The American College of Obstetricians and Gynecologists recommends that pregnant women or women planning to become pregnant avoid Paxil, if possible. Other types of treatment for depression may be a better choice.
Some babies born to mothers who are taking SSRI antidepressants show signs of “withdrawal.” For instance, they may have breathing or feeding problems. Their movements may be jerky. Some have seizures. Health providers who care for newborn babies are aware of these risks and can provide treatment. It's important for the baby's provider to know ahead of time that the mother has taken antidepressants during pregnancy.
Babies exposed to SSRIs in late pregnancy (after 20 weeks) may be more likely to have persistent pulmonary hypertension (PPHN). This rare, but serious, condition affects the lungs and blood vessels. Not enough studies have been done to know for certain if SSRIs cause the disorder. More research is needed.
Some researchers have studied children whose mothers took antidepressants. They have found no link to serious problems with language, behavior or intelligence.
Some studies have shown a link between antidepressants and premature delivery.
Choosing an Antidepressant
This decision is difficult because we don't know all the answers. No drug is entirely safe. A woman and her health care team must look at her case and carefully weigh:


The risks and benefits of various drugs
The risks and benefits of other types of treatment
The risk of untreated depression for the woman and her baby
St. John's Wort and Other Herbal Remedies
St. John's wort is an herb that some people use to treat depression. According to the National Center for Complementary and Alternative Medicine some research has shown that St. John's wort is useful for treating mild to moderate depression. Other studies have shown that it is does not help one type of major depression.

Herbal products, such as St. John's wort, vary in strength and quality from product to product. We need more research to help us know whether St. John's wort is useful and safe for treating depression in pregnant women.

IMPORTANT: We know very little about the effect of St. John's wort on the fetus. Do no take this herb or other herbal remedies without first speaking to your health provider.

Resources
The Organization of Teratology Information Services (OTIS), (866) 626-6847. Provides fact sheets on pregnancy and specific antidepressants, including Prozac and Zoloft.

Depression During and After Pregnancy, a resource for women, their families and friends, provided by the U.S. Department of Health and Human Services

July 2007