The author of this article uses a case vignette to highlight issues related to the occurrence and management of depression in pregnancy. The case subject was a 24-year-old married pregnant woman with a history of depression who presented at 10 weeks of gestation with a 1-month history of symptoms strongly suggestive of recurrent depression. After an attempt of suicide 2 years before this pregnancy, she had been successfully treated with a short course of sertraline. She was not currently suicidal and wanted to continue the pregnancy. The author describes management options for this patient, discussing issues pertinent to diagnosis and treatment of major depression.
Major depression is a common and treatable mental disorder affecting more than 12% of pregnant women. The natural course of major depression is variable in both pregnant and nonpregnant women. Over time, depression may become more severe or resistant to treatment. The likelihood of self-harm or suicide is difficult to predict and is a major consideration. A history of depression is the strongest risk factor for depression during pregnancy. Physicians or other health care providers should ask all pregnant women or women considering pregnancy about a personal or family history of mental disorders and treatment. Any woman with symptoms suggestive of depression should undergo a complete evaluation.
Untreated depression during pregnancy has been associated with increased risks of suicide, miscarriage, and preterm birth as well as poor fetal growth and impaired fetal and postnatal development. Multidisciplinary care is recommended, with involvement of the patient's obstetrician, primary care physicians, and mental health professionals. Valid choices for management include an antidepressant, cognitive behavioral therapy, and/or interpersonal psychotherapy. No safety data are available from randomized controlled trials of antidepressants during pregnancy, but observational data suggest that selective serotonin reuptake inhibitors, such as sertraline, and serotonin-norepinephrine reuptake inhibitors are relatively safe during pregnancy, although they have been associated with fetal anomalies (particularly cardiac), miscarriage, preterm birth, and persistent neonatal pulmonary hypertension. Both selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors appear to be safer than tricyclic antidepressants.
Given the previous response of the patient in the case vignette to sertraline, the author recommends using sertraline as initial treatment, with careful assessment for suicidality and side effects. Close monitoring throughout pregnancy and the first postpartum year is necessary because of the increased risk for postpartum depression.
Women's Health Program and the Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
N Engl J Med 2011;365:1605–1611