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Treating Depression in Pregnancy: Guiding Principles Vivien Burt, MD, PhD The Women’s Life Center Resnick Neuropsychiatric Hospital at UCLA

Basic Guiding Principles Overall health of the expectant mother. Depression during pregnancy increases the risk of postpartum depression.   The risk of untreated illness should be balanced against the risk of using antidepressants on the mother and baby.  The best time to organize a treatment plan is before pregnancy. Suri, R., Stowe, Z. N., Cohen, L. S., Newport, D. J., Burt, V. K., Aquino-Elias, A. R., ... & Altshuler, L. L. (2017). Prospective Longitudinal Study of Predictors of Postpartum-Onset Depression in Women With a History of Major Depressive Disorder. The Journal of clinical psychiatry, 78(8), 1110-1116. Burt, VK et al. Chapter: Treatment of Women, in APA Textbook of Psychiatry, 7th edition (in process) due to be published.

Considerations When Deciding Whether to Medicate in Pregnancy Age and fertility status Older woman Younger woman Less time to try new options More time to select from a variety of medications Less time for multiple trials of antidepressants Can wait to reach stability Assess fertility potential

Obstetric History Is she menstruating regularly? Yes No Hormonal imbalance? Better fertile potential Eating disorder? Perimenopause?

Obstetric History History of miscarriage, obstetrical difficulties, or later pregnancy losses?  If yes Will inform decision about medication in pregnancy Effect on patient’s worry about treatment

Past Psychiatric History Impact on: What medications were used to treat prior depression? Beginning or maintaining medication Dose needed to keep her psychiatrically stable Prior psychotherapy or in psychotherapy now? If so, has it been helpful? Reduce need for medication Reduce dose needed to maintain stability

Patient Medical Status Does she have medical issues that impact psychiatric stability? Rule out first! Chronic medical illness Thyroid disorders Diabetes Hypothyroidism Hyperthyroidism Fibromyalgia Effects on psychiatric well-being Treatment may relieve depression or anxiety Chronic fatigue syndrome

Social Situation Single Partner Other supports available? Are there other children in the home? Is the partner supportive?  Is the relationship stable? Resources available for child care help? Suggestion or evidence of abuse? Are they well cared for? Is help available to address their needs?

History What are the consequences of not using medications in pregnancy? Severe What have her experiences with depression been like in the past? Impact on functioning Suicidal thoughts or actions or psychosis  Has bipolar disorder been ruled out? What medications have worked in the past?

What does the patient understand about the risks to herself and her baby? How important is breastfeeding to her?

Perinatal Decision Making Transparency Risks of untreated illness Risks of antidepressant Balance and share

Truly Get to Know Patient Partner Allow wishes to inform treatment Respect patients’ wishes

Key Points The best time to devise a treatment plan in women with histories of depression is before conception. It is important to decipher the data regarding possible medications in pregnancy or the postpartum period and to explain this information to the patient and to her partner.  The treatment of perinatal depression begins with a thorough clinical and psychosocial assessment, with the goals of assessing personal risks and eliciting patient knowledge and preference. It is imperative to acknowledge and accept that patients with similar histories make different decisions regarding treatment during pregnancy.

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