Depression Treatment During Pregnancy

To the Editor: A clinical case conference by Victoria Hendrick, M.D., and Lori Altshuler, M.D. (1), addressed an urgent clinical dilemma: how to best treat depression during pregnancy. The authors correctly pointed out that clear guidelines for treating depression during pregnancy are lacking and that experts reach different conclusions about the best treatment in this situation. They provided a thorough review of treatment options, the results of published articles concerning morphological and behavioral teratogenesis, and the impact of depression on pregnancy and infant outcomes. A notable aspect of their article was the prominent place psychotherapy holds in the presentation of treatment options.

Contemporary discussions of depression treatment commonly focus on pharmacological approaches, even when the depression occurs during pregnancy. The trend appears to be an emphasis on the dangers of untreated depression and a rush to reassure physicians about the safety of pharmacological agents during pregnancy. While initial findings offer some basis for this reassurance, much remains unknown. Data concerning long-term outcomes, particularly for behavioral teratogenicity, are lacking. The quantity and quality of research on this issue (relying upon animal models, pharmaceutical company-sponsored projects, case reports, retrospective studies, and studies lacking control groups) suggests the need for an open mind about optimal treatment during pregnancy.

Unfortunately, even when psychotherapy is identified as a treatment option, it is often referred to in a cursory fashion or in a manner that downplays positive elements and emphasizes potential—although not necessarily realistic—drawbacks. These admonitory comments about psychotherapy belie the fact that it is a validated treatment approach for depression. Cognitive behavior therapy is listed in the journal Clinical Evidence as an established beneficial treatment for depression (2). Likewise, APA’s depression treatment guidelines cite data empirically supporting cognitive behavior therapy, interpersonal therapy, and other psychotherapies for the treatment of depression (3).

Given the empirical support for psychotherapeutic approaches for the treatment of depression and the need for more extensive and higher-quality research concerning the effects of pharmacological treatments of depression in pregnancy, it seems paramount to always include psychotherapy, particularly empirically validated approaches, as treatment options for depressed pregnant patients. The therapy used in the case conference was not such an approach but rather was described as an eclectic approach that combined psychodynamic and supportive modalities. Empirically validated psychotherapy should be the first choice of treatment for most depressed pregnant patients. When considering the use of medication, the risk/benefit discussion should include the fact that much is still not known about the long-term consequences of antidepressant medications.