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11/8/2023

Management of Depression in Pregnancy

Depression in pregnancy and the postpartum period is common and affects 1 in 7 women. The risk for a major depressive episode is 12% during pregnancy and 7% in the 3 months postpartum. Risk factors include history of trauma or traumatic birth, a personal or family history of depression, lack of partner support, life stress, lack of social support, and difficulty breastfeeding. Biologic factors such as serotonin-related dysregulation of the hypothalamic-pituitary-adrenal axis, elevated cortisol concentrations, and enhanced neurotropic factors may also play a role.

Screening for depression is recommended at the initial prenatal visit, later in pregnancy, and at the postpartum visit. The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used tool and is equivalent to the Patient Healthy Questionnaire -9 (PHQ- 9) in the detection of depression. Screening itself may have a positive effect on symptoms. Patients who screen positive should be connected to treatment and/or referral for mental health care.

Untreated symptomatic depression is associated with adverse outcome such as use of illicit substances and tobacco, development of concurrent medical conditions, poor maternal weight gain, and inadequate prenatal care. Risk for spontaneous abortion may be increased. Obstetric risks related to depression symptoms in pregnancy include preterm delivery and low birth weight. These associations are stronger when symptoms occur later in pregnancy. Children of depressed mothers are more likely to require psychiatric care and exhibit suicidal behavior later in life.

Treatment of depression in pregnancy includes initiation of therapy, medication, or both. Selective serotonin reuptake inhibitors (SSRIs) are the most studied category of antidepressant therapy in pregnancy. In general, evidence for teratogenicity of SSRI use in the first trimester is limited, although paroxetine should be avoided given its possible connection to congenital cardiac malformations. SSRI use in later pregnancy may be associated with transient neonatal withdrawal effects after birth such as mild respiratory distress, jitteriness, and need for neonatal intensive care unit admission. There is a modest association with persistent neonatal pulmonary hypertension, but the risk is most likely outweighed by the potential benefits of treatment. In general, optimization of symptoms with a single SSRI is best because polytherapy increases potential fetal exposure. Screening for bipolar disorder is recommended prior to initiation of SSRI treatment as 22% of patients with perinatal depression have concurrent bipolar disorder and SSRI monotherapy may precipitate mania.  Dosage adjustments (increases) may be necessary to achieve effectiveness with advancing gestation.

Patients who are using SSRIs at the time of conception should discuss continuation with their provider. One study demonstrated a 68% chance of symptom relapse when antidepressant treatment was discontinued during pregnancy. Shared decision-making and an individualized approach are important in navigating treatment options in each case. Benzodiazepine use should be avoided or minimized.

Postpartum treatment options have expanded to include intravenous allopregnanolone (a GABA modulato) which has been shown to quickly improve symptoms in patients with severe postpartum depression. Consultation with an expert on shared decision making regarding breastfeeding. SSRI use is considered compatible with breastfeeding.

Postpartum depression symptoms should be distinguished from those of postpartum psychosis, which is encountered rarely, is a psychiatric emergency and requires hospitalization. Postpartum psychosis occurs more commonly in patients bipolar disorder or may represent an initial episode of bipolar disorder or schizophrenia.

 

Further Reading:

Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 4. Obstet Gynecol. 2023 Jun 1;141(6):1232-1261. doi: 10.1097/AOG.0000000000005200. PMID: 37486660.

Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 5. Obstet Gynecol. 2023 Jun 1;141(6):1262-1288. doi: 10.1097/AOG.0000000000005202. PMID: 37486661.

Kanes S, Colquhoun H, Gunduz-Bruce H, et al. Brexanolone (SAGE-547 injection) in post-partum depression: a randomised controlled trial. Lancet. 2017 Jul 29;390(10093):480-489. doi: 10.1016/S0140-6736(17)31264-3. Epub 2017 Jun 12. PMID: 28619476.

Initial Publication November 2023. Revised July 2025.

 

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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