Early in my first year of practice as a midwife, I met Ms. K, a patient who was about 23 weeks pregnant with her third baby. Ms. K had been diagnosed with depression approximately one year prior to becoming pregnant but had abruptly stopped her antidepressants shortly after she conceived. The night I met her, she had come in for a routine “belly check” exam. When I entered the room, I noticed immediately that Ms. K was crying.
She told me that she had been very depressed for days but denied suicidal or homicidal ideation. Since she could not find a therapist who took her insurance, she was not receiving any type of counseling. We talked for a long time during the visit, and I gave her some information on local counselors and support groups. We also discussed medication, but she declined to restart antidepressants while pregnant, stating, “I’ve seen those commercials on television, and I don’t want anything to happen to my baby.” When Ms. K left the office that evening, I was frustrated that I had not done enough to help her.
I didn’t see Ms. K for another eight weeks. At her next appointment, she told me she had attempted suicide about two weeks after she had last seen me. She had received extensive therapy as an inpatient and had graduated to intensive outpatient therapy. Ms. K was also taking antidepressants. She was quiet and seemed embarrassed about the incident, but she reported feeling much better. Ms. K delivered a healthy baby boy at 39 weeks gestation, continued medication and counseling, and had no issues with postpartum depression.
Ms. K’s story is not unique. Many women suffer from depression prior to conception, but some encounter depression for the first time during pregnancy, often triggered by surging hormones and increased life stressors. Left untreated, depression during pregnancy has been shown to lead to poor prenatal care, poor weight gain, increased risk for preeclampsia and postpartum depression, use of drugs or alcohol, and suicide.
Most women are hesitant to initiate or continue pharmaceutical treatment during pregnancy, but I caution these women that the benefits of antidepressants often outweigh the risks. There are medications that should definitely be avoided – like paroxetine (Paxil) and monoamine oxidase inhibitors – but such drugs as sertraline (Zoloft) and bupropion (Wellbutrin) have been shown to be relatively safe.
No drug is completely without risk. It is important to discuss such rare but potentially serious side effects as persistent pulmonary hypertension of the newborn and cardiac defects, which are sometimes associated with antidepressants. Counseling and support are an equally important part of care of anyone suffering from depression.
Because pregnancy is traditionally regarded as a time of joyful anticipation, pregnant women may be ashamed to admit symptoms of depression. These women and their families must understand that depression in pregnancy can carry more significant risks to mom and baby than the use of antidepressants. It is crucial to provide informed consent and discuss alternative treatments with every patient as well as offer reassurance and support throughout the pregnancy and postpartum period.
Robyn Carlisle, MSN, CNM, WHNP, works as a full-scope midwife at University Doctors and Kennedy University Hospital in Sewell, N.J.