The Challenges of Managing Perinatal Depressed Mood
A major public health issue without a clear best treatment
Posted Jul 11, 2019
Limitations of mainstream treatments are stimulating research on complementary and alternative (CAM) approaches
This is the first in a series of posts on perinatal depressed mood—a serious public health issue that is not being adequately addressed by available mainstream treatments. While antidepressants are widely used to treat depressed mood during pregnancy, there is considerable controversy over their safety and efficacy. Widely shared concerns over potentially serious risks associated with antidepressant use during pregnancy have led to a recent surge in research on a variety of CAM modalities. In this post I review the consequences of inadequate treatment of depressed mood during pregnancy, and the risks and benefits of taking antidepressants during pregnancy, to the mother, the fetus and the newborn. In future posts I will provide concise reviews of the evidence for omega-3 fatty acids, folate and other natural supplements, bright light exposure, acupuncture, exercise and yoga for perinatal depressed mood.
Inconsistent findings of studies on antidepressants during pregnancy
As many as one-fourth of pregnant women experience depressed mood but few receive effective treatment (Cox et al 2016). Poor prenatal care and substance abuse increase the risk of becoming depressed during pregnancy. Inadequate treatment of depressed mood during pregnancy can have serious consequences for the mother, the unborn fetus, and the newborn. These include increased risk of maternal suicide, increased risk of preterm birth, delays in normal motor development (Hanley and Overlander 2012) and increased risk of ADHD, anxiety and mood disorders in offspring (Graignic-Philippe et al 2012; Waters et al 2014; Pearson et al 2013; Grote et al 2010; Lindahl et al 2005; Szegda et al 2014). Although many depressed women take antidepressants during pregnancy, many choose to discontinue conventional treatment out of concerns over adverse effects to themselves or the developing fetus (Mitchell et al 2011).
Research findings on the relative benefits and risks of antidepressant use during pregnancy for the mother, the fetus and, subsequently, for the newborn and developing child, are largely inconclusive (McDonagh, Matthews, Phillipi, et. al 2014). Some studies suggest that both depressed mood in the mother and fetal exposure to antidepressants increase risk of having a miscarriage (Kjaersgaard et al 2013; Anderson et al 2014). A separate study found no evidence of increased risk of miscarriage (Jimenez-Solem et al 2013). Findings on the relationship between taking an antidepressant during pregnancy and increased risk of preterm birth are also inconsistent (Byatt 2013). A meta-analysis of seven studies found that fetal exposure to an SSRI in the third trimester (but not in early pregnancy) significantly increased risk of medical and behavioral problems in the newborn such as respiratory problems, seizures, neurologic disorders, and problems nursing (Grigoriadis et al 2014).
Findings of long-term negative consequences of antidepressant use during pregnancy on infant and child development are also inconsistent (El Marroun et al 2014; Nulman et al 2012). Some studies report positive consequences such as increased infant attention and accelerated language acquisition (Hunter et al 2012; Weikum et al 2012), while others report negative consequences such as relatively lower gross motor activity and slowness in achieving adaptive social behaviors (Hanley, Brain and Oberlander 2013). There are concerns about an increased risk of developing autism in the offspring of women who take antidepressants during pregnancy, however, findings are inconsistent (Harrington et al 2014; El Marroun et al 2014).
It is difficult to distinguish the harmful effects of maternal depressed mood from the effects of antidepressants
Since both depressed mood and antidepressant use during pregnancy are associated with increased risk of medical problems in the fetus and behavioral problems in the newborn, it is difficult to determine to what extent complications at birth and developmental delays are caused by hormonal or behavioral consequences of depressed mood versus negative effects of antidepressants (Yonkers 2014).
Untreated or under-treated depressed mood during pregnancy has serious health consequences for both the mother and the fetus. At the same time, available antidepressants have potentially toxic effects on the fetus and may be deleterious to early childhood development. In this ambiguous context, emerging research findings support that select complementary and alternative (CAM) approaches may help alleviate perinatal depressed mood avoiding harmful consequences to mother, fetus and the newborn. Future posts in this series will review the evidence for promising CAM modalities and comment on reasonable integrative approaches to perinatal depressed mood that incorporate antidepressants, select natural supplements, and other non-pharmacologic treatment choices.