by Joye C. Anestis, M.S.
According to a new study in the American Journal of Psychiatry (Wisner et al., 2009), both the use of selective serotonin reuptake inhibitors (SSRIs; a common class of antidepressant medications) and untreated major depressive disorder had the same effects on the developing fetus. In this prospective observational study, the researchers divided their sample of 238 women into 5 non-overlapping groups: no SSRI, no depression; continuous SSRI exposure (took SSRIs for the entire pregnancy); continuous depression, no SSRI; partial SSRI exposure (took SSRIs at some point during the pregnancy, with at least 1 full trimester without SSRIs); partial depression, no SSRI (depression at some point during the pregnancy, with at least 1 trimester of remission). Among their many findings, they found that neither SSRI treatment nor unmedicated depression were related to minor or major psychical anomalies in the babies; however, the results indicated that both continuous depression & continuous SSRI exposure were related to premature births. This study joins a growing literature demonstrating a three-fold increase in risk for preterm births for women treated with SSRIs during pregnancy, but it also adds to this literature by demonstrating a similar effect for untreated depression.
For many women, the issue of how to tackle psychiatric problems while pregnant is a significant concern. Because the prevalence of depression in women is highest during the childbearing years (Kessler et al., 2003), the question of how best to manage antenatal depression becomes even more important (it occurs in 10% of pregnant women; Gotlib, Whiffen, & Mount, 1989; O'Hara, Zekoski, Philipps, & Wright, 1990). What was most striking to me about the Wisner et al. study is that there was no mention of alternatives to medication for the treatment of depression. This oversight was shocking considering that many studies have found psychotherapy (specifically, cognitive therapy and cognitive behavioral therapy) and medications to be equally effective in the treatment of depression and the prevention of relapse (DeRubeis, Gelfand, & Simons, 1999; Dimidjian et al., 2006; Hollon et al., 2005).
With this in mind, what do we know about alternatives to medication for pregnant women? While the clinical psychology literature on antenatal depression is sparse, several studies have demonstrated treatment efficacy for interpersonal psychotherapy (IPT) with depressed, pregnant women & adolescents (Miller, Gur, Shanok, & Weissman, 2008; Spinelli, 1997; Spinelli & Endicott, 2003). IPT is a brief treatment which focuses on interpersonal factors in the development and maintenance of mental illnesses (see Comprehensive Guide To Interpersonal Psychotherapy
; comprehensive review of IPT available through our online store for recommended products). At the outset of IPT, the patient chooses one domain of interpersonal
functioning to focus on: role transitions, interpersonal disputes,
grief, or interpersonal deficits. The focus on interpersonal
functioning, and especially the role transitions domain, seems like a
logical choice for treating pregnant women, whose depressive symptoms may be related to transitioning from a single person to a mother. There is considerable empirical support for IPT for a number of mental illnesses, including major depressive disorder (e.g., Elkin et al., 1989) and bulimia nervosa (e.g., Fairburn et al., 1995). Other forms of psychotherapy have not been systematically investigated in sample of pregnant women, but I'm not sure there is a reason to believe that psychosocial treatments known to be effective for depression in non-pregnant samples would operate differently in pregnant women.
Joye Anestis is a doctoral candidate at Florida State University.
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