To Treat or Not to Treat: That Is the Question With Perinatal Mood Disorders

Psychiatric disorders are the primary burden of disease in women of reproductive age, and unipolar depression is the leading cause of disability in women aged 15 to 44 years. Moreover, by the onset of menses, many women already have a diagnosis.

In her presentation at this year’s US Psychiatric and Mental Health Congress on perinatal mood disorders, Marlene Freeman, MD, stressed that treatment is essential for women with mood disorders but whether to treat becomes complicated during a women’s reproductive years. Clinicians must ascertain and document if a woman is pregnant or is planning on becoming pregnant. Because of mixed messages a woman can abruptly stop taking medications as soon as she becomes pregnant, which can have dire consequences: antenatal depression can negatively affect weight gain in the mother and increases the risk of low birth weight and premature birth.

Dr Freeman, Associate Professor of Psychiatry at the Harvard Medical School and Director of Clinical Services, Perinatal and Reproductive Psychiatry at the Massachusetts General Hospital in Boston, suggested that at the initial presentation, the clinician ask what the patient is doing for birth control and document that; note any bad reaction to birth control pills; document outcome of each pregnancy; medications; history of postpartum illness; losses (big factor for anxiety); problems with infertility; history or presence of abuse, eating disorders, and disordered eating behaviors. (Women with eating disorders can be better during pregnancy but are at high risk of relapse postpartum.)

As with all other patients, treatment decisions for perinatal mood disorders are based on a careful risk to benefit analysis. Although the evidence is mixed on the use of SSRIs in pregnancy, human data show no consistent associations with major congenital malformations. The joint recommendations of the American Psychiatric Association and the American College of Obstetrics and Gynecology recommend cognitive behavioral therapy (CBT) or interpersonal psychotherapy as first-line treatment for mild to moderate depression. Additional nonpharmacological treatment can include education on nutrition, weight management, prenatal care, and childbirth. First-line pharmacologic treatment is recommended for women with severe MDD.

The Massachusetts General Hospital provides an educational website on the management of mood disorders in women for clinicians and patients: www.womensmentalhealth.org.

Presentation title: Premenstrual Dysphoric Disorder and Menopausal Depression