Depression in Reproduction Flashcards
1. Describe the epidemiology of depression during pregnancy and postpartum (MKS 1f) 2. Discuss risks of antidepressant use during pregnancy (MKS 1e) 3. Review risks of Major Depressive Disorder during pregnancy (MKS 1b) 4. Present data about breastfeeding and antidepressant use (MKS 1e) 5. Be aware of the impact of pregnancy on drug disposition and the need for antidepressant dose changes (MKS 1e) 6. Learn why the FDA categorization (ABCDX) for drugs in pregnancy should not be used to guide
1
Q
What are the gender differences in prevalence of major depression?
A
- Women are approximately 1.7 times as likely as men to report a lifetime history of MDE
- Sex difference begins in early adolescence (age 10) and persists through the mid-50s
- The sharp divergence in the 50’s is based upon a small sample size and not thought to be reliable.
- Sex difference in depression is most pronounce among early adolescents, with the highest relative hazard of first onset (OR=2.3) in the age range 10-14.
- This is a consistent finding throughout the world, regardless of how depression is diagnosed
- Since women are no more likely than men to be chronically depressed or to have ana acute recurrence in the past year – therefore higher prevalence is due to higher risk of 1st onset
2
Q
What are some factors that affect women in terms of depression during pregnancy?
A
- 14.5% pregnant women-new episode of depression
- 14.5% of postpartum women-new episode during the first 3 months after birth; 21.9% in first year
- Symptoms MDD/Anx=physiological dysregulation
- Appetite and Nutrition Effects; Overweight/Obesity
- Cognitive changes; safety; prenatal care compliance
- Alcohol, drug use, smoking
- Loss of Interpersonal and Financial Resources
- Capacity for maternal attachment behaviors
3
Q
What are some common findings of major depression?
A
- For two weeks, most of the day nearly every day, 5 of these (one must be mood or interest):
- Depressed mood
- Diminished interest/pleasure
- Weight loss/ gain unrelated to dieting
- Insomnia/ hypersomnia
- Psychomotor agitation/ retardation
- Fatigue or loss of energy
- Feelings of worthlessness/guilt
- Diminished ability to concentrate
- Recurrent thoughts of death
4
Q
What birth defects that are increased in risk due to maternal stress?
A
- OR for a 3-unit change in the stress index was 1.45 (95% CI=1.03-2.06) for cleft palate
- A 3-unit change in stress assoc. with 2.35-fold ↑ risk of anencephaly among women without folic acid (CI =1.47-3.77) and a 1.42-fold increased risk among women with folic acid (CI = 0.89-2.25).
5
Q
What are the risks for depression in women in pregnancy?
A
- Recurrence risk for women who either maintained or discontinued antidepressants proximal to conception
- Significantly more women who discontinued (44/65, 68%) compared to women who maintained (21/82, 26%) antidepressant treatment suffered recurrent major depressive disorder.
- Recurrences emerged rapidly (50% in the first trimester, and 90% by the end of second trimester).
6
Q
What are the major outcomes impacted by psychiatric disorders and antidepressants that are being studied?
A
- Major birth defects (approx 3% in the general population)
- Growth/Preterm Birth
- Behavioral Teratogenicity
7
Q
How do SSRIs affect congenital defects?
A
- Specific defects have small risk
- Congenital defects, especially cardiac defects are related to depression and NOT SSRIs
8
Q
How are SSRIs related to growth and preterm growth?
A
-
Pregnancy duration, Birth weight
- Small for Gestational Age (SGA) infants inconsistently reported with SSRI exposure
- PTB associated with SSRI
- SGA and Preterm Birth associated with MDD
- However, depression may be the underlying cause, but not enough studies yet
9
Q
What is the relationship between SSRIs and preterm birth?
A
- Rates of preterm birth higher in women on SSRIs
- However, depression throughout pregnancy also gave similar rates
- Suggests that if there is depression, there is something about the illness that increases the risk of preterm birth
- Unclear if the medication has a separate mechanism or not
10
Q
How do SSRIs and MDD affect growth after birth?
A
No effect
11
Q
How do SSRIs and MDD affect neurological development of infants?
A
- No effect on mental development
- Longer duration of prenatal SRI exposure insreases risk for lower PDI (motor development) in infants
- Motor differences gone at 19 months, may be a transient dip at around 52 weeks
12
Q
Are SSRI-treated womoen really better?
A
Mixed results, one study shows that there is some improvement if treated with SSRIs
13
Q
What are some important factors in providing optimal treatment for women who are depressed during pregnancy?
A
- Once the decision is made to use medication, treat optimally to provide the maximal reduction in disease burden
- Document all exposures (drugs, alcohol, environmental)
- Document risk-benefit discussion and patient’s reason for decision
- Use a standard symptom monitoring measure (PHQ-9)
14
Q
How does drug levels change across pregnancy? How does this impact management?
A
- Much higher active drug levels during pregnancy despite no changes in dose
- Means that after delivery, simply increase dose, no need to change drugs
15
Q
What are some non-drug therapies that have been shown to be effective for pregnant women?
A
- Psychotherapy, many forms!
- Bright Light Therapy
- Seasonal and non-seasonal MDD
- 30-60 mins commercially available, UV-screened 10,000 lux fluorescent light, within 10 mins of awakening
- Acupuncture for depression during pregnancy
- Aerobic Exercise (> 30 minutes of moderate intensity physical exercise, 3 to 5 days per week)
