Mental health problems in pregnancy

🔹 Risk Factors for Perinatal Depression

🔸 High Correlation with Increased Risk

• Depression during pregnancy
• Personal history of affective disorder
• Family history of affective disorder
• Lack of social support (especially from partner or mother)
• Multiple concurrent stressors

🔸 Some Correlation with Increased Risk

• Perfectionistic personality traits
• Low socioeconomic status
• Aboriginal and Torres Strait Islander background
• History of childhood abuse

🔹 Screening Considerations

• A high score on the Edinburgh Postnatal Depression Scale (EPDS):
  • Does not confirm psychiatric illness
  • May indicate a need for further assessment or support
  • May not lead to treatment uptake due to stigma, denial, or other barriers

🔹 Barriers to Help-Seeking

• Fear of stigma or being seen as a “bad mother”
• Reluctance to take medication during pregnancy/breastfeeding
• Misconception that planned/wanted pregnancies are immune to depression
• Preference for being listened to over receiving quick prescriptions
• Concern about medication safety due to lack of knowledge

🔹 Clinical Approach

• Initial management should focus on:
  • Education
  • Psychosocial support
  • Non-pharmacological interventions
• Avoid immediate prescription unless clearly indicated
• Build a therapeutic alliance through empathy and shared decision-making

🔹 When to Consider Antidepressants

• Severe depression or prominent biological symptoms (e.g. appetite/sleep disturbance)
• Persistent symptoms despite time or support
• Failure of psychosocial interventions (nil or inadequate response)
• Barriers to psychosocial support (e.g. cost, distance, lack of access)
• Past or family history of effective response to antidepressants
• Patient preference after informed discussion

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Antidepressant use during pregnancy

https://australianprescriber.tg.org.au/articles/antidepressants-in-pregnancy-and-breastfeeding.html

🔹 Background & Context

• Maternal depression/anxiety during pregnancy and postpartum can significantly affect maternal and infant health.
• Suicide risk and adverse birth outcomes (e.g. low birth weight, preterm birth) are major concerns.
• Antidepressant decisions require balancing the risks of untreated depression against medication safety.
• No RCTs exist in pregnant/lactating women → guidance is from observational data and clinical experience.

🔹 Harms of Untreated Maternal Depression

During Pregnancy

• Associated with:
  • Shorter gestational age
  • Lower birth weight
  • Elevated cortisol in offspring (linked to long-term psychopathology)
  • Early maternal ambivalence → behavioural/learning issues (esp. boys)

During Lactation

• Depressed mothers more likely to cease breastfeeding early.
• Breastfeeding mothers less likely to develop postnatal depression.
• Complex bidirectional relationship between lactation and mood.

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🔹 Antidepressant Risks in Pregnancy & Lactation

Tricyclic Antidepressants (TCAs)

• Declined in use due to overdose toxicity.
• Limited data, but generally considered relatively safe.
• Avoid doxepin in breastfeeding (case reports of infant toxicity).
• Dothiepin may have beneficial infant outcomes in one small study.

Mirtazapine

• Sparse data.
• Not first-line in pregnancy.
• Low levels detected in breastmilk.

Venlafaxine

• Associated with:
  • ↑ Spontaneous abortion risk (early pregnancy)
  • Neonatal adverse effects (accumulation with prolonged use)
• Use with caution in both pregnancy and lactation.

Mood Stabilisers (for bipolar depression)

• Sodium valproate: Highly teratogenic → avoid in 1st trimester.
• Lithium:
  • Teratogenic risk (esp. cardiac) ↓ in newer data.
  • Requires infant monitoring if used during lactation (TFTs, renal, serum lithium).
  • Specialist input advised.
• Lamotrigine: Specialist advice recommended.

🔹 SSRIs in Pregnancy

First Trimester

• Initial data: no teratogenicity.
• Newer data: slight increase in birth defects (not statistically significant).
• Paroxetine: associated with congenital cardiac defects (risk ↑ with doses >25 mg/day).

Second & Third Trimesters

• Small increased risk of:
  • Prematurity
  • Low birth weight
  • Neonatal complications: respiratory distress, irritability, feeding difficulties.
• Paroxetine may cause more neonatal issues (but not consistently found).
• Self-limiting symptoms, usually resolve in <14 days.

Serious but rare reports:

• Persistent pulmonary hypertension of the newborn (PPHN)
• Intraventricular haemorrhage

🔹 SSRIs in Lactation

• Highly protein bound → low transfer to infant in most cases.
• Generally considered safe in breastfeeding, though:
  • Variability in infant serum levels
  • Rare case reports of adverse effects

🔹 Clinical Management

• Assessment:
  • Early and thorough mental health review, ideally involving family.
  • Assess suicide/self-harm risk and antenatal care engagement.
• Planning:
  • Use a biological–psychological–social treatment framework.
  • Informed consent and documentation are essential.
• Preconception counselling:
  • Weigh relapse risk vs drug exposure.
  • Trial withdrawal before conception may be attempted in stable women.
• Unplanned pregnancy:
  • Abrupt cessation → 75% relapse risk before delivery.
  • Reassess and possibly continue antidepressants.
• Later pregnancy:
  • Consider dose reduction before delivery to reduce neonatal withdrawal/toxicity.
  • Some women manage well with tapering + psychosocial support.

🔹 Antidepressant Choice

• First-line: SSRIs preferred over TCAs, SNRIs, mirtazapine.
• SSRIs with shorter half-lives (e.g. sertraline, citalopram, fluvoxamine) preferred.
• Paroxetine: caution at high doses.
• Fluoxetine: long half-life, possibly slower withdrawal effects in neonates.

🔹 Resources

• OTIS (www.otispregnancy.org) – reliable, up-to-date source.
• Australian hospital-based perinatal pharmacy services.
• GP PsychSupport (1800 200 588) for psychiatric advice.
• Pharmaceutical company data (with caution).

🔹 Conclusion

• Weigh illness burden vs treatment risks across pregnancy/lactation phases.
• Antidepressants can be safely used with:
  • Judicious agent selection
  • Close maternal/neonatal monitoring
  • Patient education and support
• Postnatal SSRI use: generally safer and potentially beneficial.