Depression

INFORMATION FOR WOMEN WHO HAVE DEPRESSION DURING PREGNANCY OR BREASTFEEDING

The information provided below is for readers based in the United States of America. Readers outside of the United States of America should seek the information from local sources.

What is depression?

While being pregnant can trigger episodes of depression, the symptoms of depression are no different in pregnant women than in non-pregnant women. Women are considered to have mild to moderate major depression if they experience 5 or more of the following symptoms for periods lasting 2 or more weeks:

  • Feeling moody, sad, overwhelmed, or crying a lot
  • Losing interest in most or all activities that used to give you pleasure 
  • Difficulty sleeping or sleeping too much
  • Eating too little or too much, causing changes in your weight
  • Low energy, slowed-down thinking or feeling hyper and having high energy
  • Poor concentration, difficulty focusing and making decisions, poor memory
  • Thoughts of worthlessness, guilt, and hopelessness
  • Recurrent thoughts about death or suicide

Severe depression is much worse than mild or moderate depression and is diagnosed if you:

  • Have thoughts about death
  • Make an attempt to kill yourself or threaten to kill yourself
  • Become aggressive and threaten other people
  • Experience delusions (convinced of things that are not true) or hallucinations (convinced of things that are not there)
  • Become unable to take care of yourself or your children  

Women who have a history of depression are more likely to be depressed during pregnancy. Other risks for developing depression during pregnancy include a family history of depression or bipolar disorder, single motherhood, cigarette smoking, having more than three children, low income, aged 20 or younger, poor social support, and domestic violence.

How common is depression during pregnancy?

Depression is common during pregnancy – between 14 and 23 percent of pregnant women will experience depression while pregnant.

How is depression during pregnancy diagnosed?

Common changes of pregnancy like feeling tired, nauseous, and moody can be mistaken for depression. Concerns about the pregnancy, your ability to care for the baby, or changes in your relationship with your partner are common. Such concerns should be in balance with the joys of planning for motherhood and the anticipation of meeting your baby. If not, talk to your health care provider about your worries.  Your pregnancy care provider can help to determine if your feelings might be caused by an underlying depression. They may ask you to fill out a depression questionnaire to help determine if you are experiencing depression. If it does appear that you are experiencing depression, a referral to a mental health specialist may be made to help treat your depression.

Does depression cause problems during pregnancy?

Women who are depressed make fewer visits to their health care provider and use more alcohol, drugs, and tobacco during pregnancy than women who are not depressed. They may also experience more pregnancy complications such as nausea, vomiting, high blood pressure (preeclampsia), and postpartum depression. Other concerns include poor eating habits and anorexia, increased tension in relationships with family and friends, and a higher risk of suicide.

Does depression cause problems for the baby?

Infants born to women with depression tend to be smaller and could be born before their due date (premature). These infants may be more irritable, less active, less attentive, and less interactive with their mothers and other people.

What to consider about taking medications when you are pregnant or breastfeeding:

  • The risks to yourself and your baby if you do not treat the depression
  • The risk of depression returning if you stop taking your medication or if you switch to a different medication.
  • The risks and benefits of each medication you use when you are pregnant
  • The risks and benefits of each medication you use when you are breastfeeding

What should I know about using medication to treat depression during pregnancy?

Approximately 15 percent of women take an antidepressant at some time during their pregnancy.

Whenever possible, a management plan for depression should be coordinated between the pregnancy care provider, mental health clinician, and the woman prior to getting pregnant in order to avoid or minimize the use of medications that increase the risk of birth defects. If a medication is started during pregnancy, the idea is to choose a medication that is most effective for treating the mother’s depression and least harmful to the developing baby.

If your depression has been well-controlled with low to moderate medication dosages, you may want to consider tapering off your medication before becoming pregnant, especially if you have been symptom-free for 6 months or longer. It is important to discuss this with your doctor before deciding to stop any medication because your depression may come back or worsen if the medication is stopped suddenly. Other problems that may occur if you suddenly discontinue your medication include nausea and vomiting, chills, fatigue, anxiety and irritability.

Who should NOT stop taking medication for depression during pregnancy?

Discontinuing antidepressant medication may not be appropriate for women who have:

  • A history of severe, recurrent depression
  • A history of suicide attempts
  • Other psychiatric illnesses
  • Have not been adequately controlled by medication and/or psychotherapy

If you are not sure about whether or not to stop your medication, it is a good idea to talk with your mental health care provider about potential risks of drug discontinuation. Understanding which risks are relevant to you may help you decide if stopping your anti-depression medication will cause more harm than good.

What should I know about choosing a medication for my depression during pregnancy?

It is often difficult to decide whether to use medication during pregnancy, especially since there is no guarantee that the medication will be safe for the mother or the baby. Always talk to your health care provider before starting, stopping, or changing any medication during pregnancy.

Selective serotonin reuptake inhibitors (SSRIs) are the most common type of anti-depression medication prescribed during pregnancy. Most of these medications appear to be safe to use during pregnancy. A large study evaluated birth defects associated with the use of citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) during pregnancy and the results showed that the risk of specific birth defects increases with the use of fluoxetine and paroxetine only.

Babies whose mothers used fluoxetine during the first trimester are at higher risk of heart defects and birth defects of the skull (craniosynostosis). Previous b
irth defects that had been linked to fluoxetine in earlier, conflicting reports do not appear in newer, more detailed studies. Paroxetine use appears to be linked to five different birth defects, including a serious malformation of the brain and skull called anencephaly, a type of heart defect called atrial septal defect, heart defects with obstruction of the right ventricular outflow tract, and 2 different birth defects of the abdominal wall known as gastroschisis and omphalocele.

While there is evidence that suggests that certain SSRIs are linked to birth defects, this risk is still very small: the risk of having a baby with anencephaly for a woman not taking any medications in pregnancy is 2 per 10,000 babies. The risk for a woman taking paroxetine is 7 per 10,000 babies. The best way to understand how these risks apply to you and your baby is to discuss them with your doctor or health care provider.

There is evidence that babies exposed to SSRIs during the third trimester may experience withdrawal symptoms during the first few days after birth. These have included irritability, jitters, and poor feeding. Decreasing the dosage of medication during the third trimester does not appear to decrease this risk and has generally been discouraged. A rare but serious lung problem called persistent pulmonary hypertension may also be seen in babies exposed to certain SSRIs during the third trimester. The actual risk of this happening is still unknown.

Serotonin and norepinephrine reuptake inhibitors (SNRIs), such as duloxetine (Cymbalta) and venlafaxine (Effexor XR), can also be used to treat depression during pregnancy. No specific birth defects have been linked to either medication but they both have similar risks to the SSRIs if they are used during the third trimester.

Less commonly used medications for depression are the tricyclic antidepressants and bupropion (Wellbutrin). They are generally considered less effective options for treating depression but both types of drugs do appear to be safe for use during pregnancy. No data show birth defects linked to these drugs; however, some data have linked bupropion to attention-deficit/hyperactivity disorder (ADHD) in babies exposed during pregnancy. The amount of evidence is small, so the risk of a baby developing ADHD cannot be determined with any certainty at this time.

You may find Pregistrys expert reports about the individual medications to treat depression here. Additional information can also be found in the sources listed at the end of the report.

What should I know about taking a medication for my depression when I am breastfeeding?

Medication that is effectively controlling a patients depression should not be changed if she decides to breastfeed her baby. Most physicians believe that the benefits of breastfeeding outweigh the risks of an infants exposure to antidepressants. So, if you are taking an antidepressant that is working well for you, the risk of doing any harm by breastfeeding your baby is low.

If you are considering stopping an anti-depression medication while breastfeeding, it is important to remember that babies are very sensitive to their mothers moods. So, if stopping your medication will cause your depression to return, this may have a more significant impact on your baby than continuing using the medication.

What alternative therapies besides medications can I use to treat my depression during pregnancy?

Getting regular exercise is a great and healthy way to help with depression. It can be any type of exercise including walking, swimming, or yoga. Getting your exercise outdoors adds the bonus of getting a bit of sunshine, which may also help improve your mood. If you have any concerns about what type of exercise is safe for you during pregnancy, ask your pregnancy care provider.

While there is no conclusive evidence to suggest a particular diet change, some experts agree that getting enough omega-3 fatty acids and folic acid may help ease depression. Both of these nutrients, in moderate amounts, are great for all women during pregnancy, so making sure you are getting enough in your diet to help your depression is a good idea. 

Some people looking for a natural way to treat depression may consider using the herbal supplement St. Johns wort since there is some evidence it may help with mild depression. However, St. Johns wort is not recommended for pregnant or breastfeeding women because there is very little data to show that it is safe.

Counseling or therapy?

If you have mild or moderate depression, you may not need to treat it with medication. Both interpersonal therapy and cognitive-behavioral therapy have been shown to be effective to make people feel better. These are good options for women who want to avoid taking medication during pregnancy. Therapy can help decrease negative thoughts and beliefs and increase your ability to cope with the changes that pregnancy and having a baby can bring.

Combining counseling with low dose medication may be the most effective approach for pregnant women who do not find sufficient relief of symptoms from psychotherapy alone. Talking to both your therapist and your doctor can help to find the right balance for you.

Electroconvulsive therapy (ECT)

For severely depressed pregnant patients who have not been adequately responsive to antidepressant medication, ECT is considered to be safe and effective during pregnancy with rapid therapeutic effect.

What can I do for myself and my baby when I have depression during pregnancy?

Whether you are planning to become pregnant or you are already pregnant, you will want to discuss your depression and your medication with your health care providers including your mental health provider, pregnancy provider and the therapist you see for your depression. Antidepressant medication should never be stopped right away, but the dosage may be decreased slowly over a period of a few months for patients with well-controlled mild to moderate depression. This allows you to see if your depression symptoms start to return, or if you can continue taking the medication at a lower dose or not at all.

Stopping antidepressant medication is not for everyone. Since it does appear that the risks to the pregnancy from depression medication are small, some women may find that the benefit of treating their depression with medications outweighs the potential risks of the medications to themselves and to the developing baby. It is important that women with depression feel that they are able to take good care of themselves during pregnancy. If not treating your depression during pregnancy means that you are not eating well, sleeping poorly, or turning to alcohol, drugs, or tobacco to cope with your depression, then talking with your doctor about medications is important.

Resources for depression in pregnancy:

For more information about depression during and after pregnancy, call womenshealth.gov at 800-994-9662 (TDD: 888-220-5446) or contact the following organizations:

 

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General information

It is very common for women to worry about having a miscarriage or giving birth to a child with a birth defect while they are pregnant. Many decisions that women make about their health during pregnancy are made with these concerns in mind.

For many women these concerns are very real. As many as 1 in 5 pregnancies end in a miscarriage, and 1 in 33 babies are born with a birth defect. These rates are considered the background population risk, which means they do not take into consideration anything about the health of the mom, the medications she is taking, or the family history of the mom or the baby’s dad. A number of different things can increase these risks, including taking certain medications during pregnancy.

It is known that most medications, including over-the-counter medications, taken during pregnancy do get passed on to the baby. Fortunately, most medicines are not harmful to the baby and can be safely taken during pregnancy. But there are some that are known to be harmful to a baby’s normal development and growth, especially when they are taken during certain times of the pregnancy. Because of this, it is important to talk with your doctor or midwife about any medications you are taking, ideally before you even try to get pregnant.

If a doctor other than the one caring for your pregnancy recommends that you start a new medicine while you are pregnant, it is important that you let them know you are pregnant.

If you do need to take a new medication while pregnant, it is important to discuss the possible risks the medicine may pose on your pregnancy with your doctor or midwife. They can help you understand the benefits and the risks of taking the medicine.

Ultimately, the decision to start, stop, or change medications during pregnancy is up to you to make, along with input from your doctor or midwife. If you do take medications during pregnancy, be sure to keep track of all the medications you are taking.



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