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

3. 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),
Burt, VK et al. Chapter: Treatment of Women, in APA Textbook of Psychiatry, 7th edition (in process) due to be published.

4. 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

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

6. 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

7. 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

8. 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

9. 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?

10. 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?

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

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

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

14. 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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