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4 Options for Navigating Depression in Pregnancy

 

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While pregnancy is typically thought of as a time for celebration and “basking in the glow of new life,” many women struggle through this period of their lives. Up to 16% of pregnant women meet the diagnostic criteria for major depression, and figuring out how to navigate this is a challenge for both pregnant women and their care providers. As a Naturopathic Doctor with full prescribing rights and an exclusive focus on pregnancy, this is something I receive a lot of questions about.

If you are struggling with depression, know that you don’t have to do it alone: the best first step you can take for you and your baby is to talk to your doctor.

If you are lost in the conflicting information online about this issue, this post (and the research articles attached) outlines the challenges and some options I consider in my own clinic and with my online pregnancy coaching program (My Healthy Pregnancy Plan). Everything here is based on the best evidence-based integrative medicine available, in the hope that it helps you navigate your options and find some relief throughout your pregnancy.

Challenges:

  • Shame: Many women struggle with their depression alone because they are too ashamed to ask for help – there is a lot of guilt associated with feeling miserable when everyone thinks you should be overjoyed, and it is crucial that care providers create a safe space for women to share their concerns about their mental and emotional health, without fear of judgment.
  • Difficulties diagnosing: Depression during pregnancy can be confusing – many of the symptoms are considered “normal changes of pregnancy”– including fatigue, sleep problems, irritability, tearfulness, moodiness and eating changes. Outside of pregnancy these would be considered red flags, but during pregnancy are often be written off as “just your hormones.”

    A full assessment by a qualified care provider is needed to determine whether a diagnosis of depression is indicated, and the level of severity.

  • No easy solutions: There is a lack of consensus around treating depression during pregnancy – it is acknowledged that leaving severe depression untreated poses risks to both mother and child, and also that there are no fully safe (Category A) prescription or herbal options for mothers (see footnote [1] for what this means), leaving a bit of a Catch-22:
    • Risks of not treating depression: increased rates of adverse outcomes (premature birth, low birth weight, fetal growth restriction and postnatal complications), and increased risk of postpartum depression, which can sometimes have tragic consequences.
    • Risks of treating depression with prescription medications: All medications used for mental health cross the placenta, thus exposing the developing fetus to these drugs and increasing the risk of miscarriage, pre-term birth, low birth weight, withdrawal symptoms at birth (including restlessness, irritability, tachypnea, hypoglycemia and fetal pulmonary hypertension), and increased risk of cardiac malformations (with Paxil specifically).

Best-evidence treatment options:

With any concern of depression, it is imperative to have your level of depression assessed by a qualified care provider. It is also important to rule out medical conditions that could be contributing to your depression, including anemia, hypothyroidism, hypoglycemia, and malnutrition.

Your care provider will consider the level of severity of your depression before making treatment recommendations. Here are some of the best-evidence treatment options for you to explore as you make a decision about what is best for you and your baby:

Lifestyle and dietthese should be considered first-line therapy in cases of mild-to-moderate depression

  • Nutrition:
    • Have your diet assessed to ensure adequate protein and healthy fats, a quality prenatal vitamin, and sufficient calories
    • Keep your blood sugar stable by avoiding high glycemic foods
  •  Sleep:
    • Improve your “sleep hygiene” (including no screen time 30 minutes before bed, and allowing for 7-8 hours per day of sleep)
    • Take a cat nap mid-day when you need one!
  •  Exercise:
    • Try to get 30 minutes of exercise every day, ideally outside and with a friend/partner
    • Consider group prenatal yoga classes, which have been shown to significantly reduce depressive symptoms in pregnant women
  • Omega-3 supplementation:
    • Omega 3 levels have been found to be lower in depressed pregnant women – consider omega 3 supplementation (minimum 500mg each of DHA and EPA)

Complimentary Therapiesused as adjunctive therapy with lifestyle or prescription therapies

  • Counselling/psychotherapy:
    • Cognitive behavioural therapy (CBT) has shown to be particularly effective for depression in pregnant women
  • Acupuncture:
    • Acupuncture has been shown to be an effective treatment for women with major depressive disorder in pregnancy

Herbal medicineused for severe depression, or when lifestyle and complimentary therapies are inadequate to control symptoms of depression – should not be combined with pharmaceuticals

  • Like pharmaceuticals, there are no category A herbal options for depression. The best herbal option is St John’s Wort (SJW), which is Category B
  • SJW should not be combined with anti-depressants due to risk of increase adverse effects and causing seretonin syndrome – choose one treatment or the other, not both
  • Caution: St John’s Wort can alter effectiveness of other medications due to effect on liver enzymes – always consult your care provider before beginning a herbal medication in pregnancy

Prescription therapiesused for severe depression, or when lifestyle and complimentary therapies are inadequate to control symptoms of depression

  • Like herbal medicines, there are no Category A pharmaceuticals to treat depression in pregnancy, and as such are used conservatively (i.e. the safest medication is chosen, at the lowest effective dose)
  • Category B: Wellbutrin is the only Category B option, but is not generally considered first-line treatment for depression
  • Category C: the majority of anti-depressants fall into this category, including:
    • Tri-cyclic antidepressants like Amitriptyline and Nortriptyline
    • SSRIs like Prozac and Zoloft (Paxil is the exception)
    • “Other” antidepressants like Effexor and Cymbalta

Category D: Paxil is rated Category D and is to be avoided in pregnancy due to risk of fetal cardiac malformations. Patients who have been exposed to Paxil during early pregnancy are recommended to have a fetal echocardiogram.

Navigating treatment options for depression in pregnancy is very difficult – there is no one “right answer” or treatment that makes sense for everyone. What is most important is that you seek the support you need for your and your baby’s health.

I hope that this information helps you and your care provider make the right decision for yourself and your baby.

If you haven’t done so already, sign up for my free cheat sheet: 8 shortcuts To A Healthy Pregnancy – and stay up-to-date with more great information and announcements about the My Health Pregnancy Plan program.

In health,

Dr Jocelyn Land-Murphy, ND

Terra Life

Disclaimer: The information and content provided is for general educational and informational purposes only and is not professional medical advice, nor is it intended to be a substitute therefore. Please consult the Disclaimer and Terms of Use for full details.

References:

Armstrong, C. (2008). ACOG Guidelines on Psychiatric Medication Use During Pregnancy and Lactation. Am Fam Physician, 78(6): 772-778.

Bonari, L. et al. (2004). Risks of untreated depression during pregnancy. Canadian Family Physician, 50: 37-39.

Lin, P.-Y. et al. (2010). A Meta-Analytic Review of Polyunsaturated Fatty Acid Compositions in Patients with Depression. Biological Psychiatry, 68(2): 140-147.

Manber, R. et al. (2010). Acupuncture for Depression During Pregnancy: A Randomized Controlled Trial. Obstetrics and Gynecology, 115(3): 511-520.

Mills, S., & Bone, K. (2005). The Essential Guide to Herbal Safety. St Louis: Churchill Livingstone.

Moretti, M. (2009). Evaluating the safety of St. John’s Wort in human pregnancy. Reproductive Toxicology 28(1): 96-99.

Muzik, M. et al. (2012). Mindfulness Yoga during Pregnancy for Psychiatrically At-Risk Women: Preliminary Results from a Pilot Feasibility Study. Complement Ther Clin Pract, 18(4): 235–240.

Natural Medicines Professional Database (n.d.). St John’s Wort. Retrieved from https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs-supplements/professional.aspx?productid=329

Romm, A. (2009). Botanical Medicine for Women’s Health. St Louis: Churchill Livingstone.

Yonkers, K. et al. (2009). The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. General Hospital Psychiatry, 31(5): 403-413.

Footnotes:

[1] Category A: Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).

Category B: Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women.

Category C: Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Category D: There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

 

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