Medication is always a sensitive issue when it comes to pregnancy. This is because pregnancy is an exceptional situation in which medication taken by the mother can also affect the fetus.
Different countries have different guidelines on the use of antidepressants during pregnancy. Indeed, while symptoms of gestational depression are common across international borders, there is considerable variation in recommended interventions.
Postpartum depression has gained visibility in recent years, shattering the myth that the period after pregnancy is always a happy one. However, a woman can develop depression before or during pregnancy. In fact, the term perinatal depression includes depression during pregnancy and within a year after childbirth.
New research results show that different European countries have different guidelines for perinatal depression and medication use. In some countries there are not even any guidelines. Let’s take a look at the main differences between countries in this regard.
Antidepressants in pregnancy
Peripartum or perinatal depression affects about one in eight women. These two terms tend to be used interchangeably. However, the former term relates more specifically to women. The disorder usually persists throughout the peripartum period. In fact, up to 47 percent of women with postpartum depression have experienced a prenatal period.
In most cases, depression coincides with anxiety. This adds a significant mental health burden to the woman. Therefore, they may need specialized interventions, including pharmacotherapy. It all depends on the course of their individual depression, the time of onset and the typology of symptoms that are evident. It is usual to recommend psychotherapy as a first option, followed by medication. However, it should be noted that practices differ from one country to another. Indeed, despite a great deal of interdisciplinary research, an international understanding of the problem is still lacking.
Perinatal depression
Perinatal depression is associated with a range of adverse long-term obstetric outcomes in offspring. These include possible negative effects on the mother-infant relationship. It also significantly affects women’s well-being and functioning and can even lead to suicide. In moderate to severe cases, or after failure to respond to first-line psychotherapy, pharmacotherapy with antidepressants is usually required. Pooled results from 40 cohort studies show that selective serotonin reuptake inhibitors (SSRIs) are the most commonly used antidepressants.
Prescription of these drugs ranges from 3.5 percent before pregnancy, 3.0 percent during pregnancy and 4.7 percent in the first year postpartum. In some cases, augmentation with antipsychotics or additional pharmacotherapy with sedative benzodiazepines or antihistamines may be necessary.
Pros and cons
Pregnancy remains an important factor for discontinuation of antidepressants. Of those who chose to continue treatment, 49 percent had low antidepressant adherence. In conclusion, the decision-making process regarding antidepressant treatment during pregnancy or breastfeeding is complex.
The process involves weighing the risk of in utero or breast milk exposure against the potential adverse effects of inappropriately treated maternal peripartum depression for both mother and child. Clinical practice guidelines (CPGs) for the management of peripartum depression can facilitate this decision-making process. However, many countries have not established CPGs for peripartum depression. Furthermore, existing recommendations are not always uniform.
In 2018, a systematic review assessing the content of existing CPGs found that only four countries recommended continuing pre-existing antidepressant treatment during pregnancy. This previous study only extracted CPG recommendations that met the quality criteria of the Assessment of Guidelines for Research and Evaluation (AGREE) tool.
Therefore, knowledge gaps remain about the current practice of CPGs that do not meet these quality criteria. Furthermore, the extent to which CPGs are followed with regard to the prescribing of antidepressants and other psychotropic medicines is unknown.
Different cultures and medication use in pregnancy
In some Eastern European countries, the use of benzodiazepines in pregnant women is much more common than antidepressants. This tends to happen even when antidepressants are the preferred choice for anxiety, the condition for which benzodiazepines are usually prescribed.
Benzodiazepines are a group of medicines for the short-term treatment of sleep disorders. They relieve restlessness and anxiety and reduce muscle tension and cramps. However, benzodiazepines are not recommended for use in pregnant women because they pose a greater risk to the child than antidepressants. There is also a risk of addiction and abuse with benzodiazepines. As new information is always emerging in this field, it is not surprising that different countries have common guidelines for the same symptoms.
Results found in Denmark
It was found that the risk of serious mental illness increased if the mother stopped taking antidepressants during pregnancy, but not if she stopped before becoming pregnant.
This is an example of new information that should be reflected in guidelines for patients. In this case, it is probably understandable that the data has not yet been included as it is a completely new study. However, there are also many cases where guidelines have not been updated in light of recent findings.
Helping the mother is paramount
In certain settings, pharmacological treatment for pregnancy depression can be really difficult to obtain. For fear of harming the fetus and on medical advice, the mother may change the medication, reduce the dose or stop taking it.
Obviously, the care of the fetus is paramount. However, there is a reason why the mother needs antidepressants and this reason does not disappear during pregnancy. Indeed, there are even symptoms that can worsen. Therefore, when it comes to perinatal depression, we can say that when we help the mother first, we help the child better.
New ways to help mom
Despite a lot of interdisciplinary research, there are still no harmonized cross-border guidelines, claims researcher Angela Lupattelli from the Department of Pharmacy at the University of Oslo (Norway). Lupattelli is one of three Norwegian participants in the Riseup-PPD COST ACTION, a major EU-funded initiative to find and collect information on what researchers call perinatal depression.
The researchers will also investigate new drug formulations, where the findings are currently being mixed. Light therapy, omega-3 fatty acids, electrotherapy and magnetic therapy are among the solutions being studied. Meanwhile, work is being redoubled on prevention policies to reduce the number of cases requiring pharmacological intervention.
The Riseup-PPD COST ACTION research study started in 2019 and will be completed in 2023. By then, the researchers hope to have a clear understanding of perinatal depression. This will serve as a basis for setting guidelines in different countries. The strength of the study is that it involves women experiencing this type of depression. Experts will be able to make important adjustments in the future thanks to the experiences they share.
