Treatment of MDD in Females of Childbearing Age

Andrew J. Cutler, MD:Let’s shift gears and talk a little about depression in women. A question we get asked all the time, Sagar, is how do we think about treating depression in females who are of childbearing potential and are frankly interested in starting a family?

Sagar V. Parikh, MD, FRCPC: We first have to acknowledge that depression is more common in women, of course, and that there wasn’t a time when we thought pregnancy was somehow protective against getting depressed or something. But we know now that in fact, there’s a lot of emotional turbulence during pregnancy, and particularly individuals who’ve had depressions in the past who may be well now and are thinking of becoming pregnant, they’re still at extremely high risk for relapsing, not just in the postpartum period, but maybe late in pregnancy. The idea of what medicines are safe during pregnancy becomes very much of concern. To the extent that people can take it and it’s available, mindfulness-based CBT [cognitive behavioral therapy] is the strongest psychotherapeutic preventer of fresh episodes of depression. That might be 1 treatment, and that’s usually 8 sessions, a 90-minute group done 8 times; it’s well studied in traditional RCTs [randomized controlled trials]. That would be one thing. With respect to the other medications, we know a lot more about older medications, so that might be one option. And if it emerges that episodic treatment will suffice, then perhaps we can try a 2-week treatment episodically, and hopefully, that’ll last the duration of the pregnancy.

Andrew J. Cutler, MD: That is interesting, absolutely. Greg, my understanding is that SSRIs [selective serotonin reuptake inhibitors] have been shown to be reasonably safe during pregnancy, but how do you handle these kind of questions?

Gregory Mattingly, MD: I start with, once again, a holistic discussion about how depression can affect not just the mom, but also the child inside the mom.

Andrew J. Cutler, MD: That’s true.

Gregory Mattingly, MD: One of the biggest risks is the mom getting depressed. All of our studies out there have shown that depressed moms have higher rates of premature delivery, increased fetal distress, problems bonding to their children after they’re born, failure to thrive, all of those things. I legitimize it to the mom, and say, “It’s OK to take care of yourself. It’s important to take care of yourself. Because when you take care of yourself, you’re taking care of the baby inside of you. Now, when we talk about treatment options, let’s talk about what treatment we need to keep you healthy during this pregnancy.” If that treatment option can be being off medicine during pregnancy, that’s an option for a few of my patients. For many of my patients, it’ll be talking about how we keep them healthy. The other thing I do for all of my pregnant patients, Sagar, is schedule a visit 1 week after their due date. I want to preventively and proactively manage that postpartum period in all of my patients. We talk about what we’re going to do during pregnancy, and what are our strategies, we’ll schedule some visits during the pregnancy. I’ll discuss it with their OB-GYN [obstetrician-gynecologist] if we do need to stay on medicines. But then I proactively schedule a visit 1 week after their due date.

Sagar V. Parikh, MD, FRCPC: If I could share another thing I do, historically, I’ve treated many more women with bipolar disorder than with unipolar depression. We actually draw up a pregnancy contract. Almost universally, women want to be off medications when they want to become pregnant. And that’s very understandable, regardless of what other safety data there may be for this medicine or that medicine. What we do is draw up a little contract, which basically says, “When I get depressed, these are my common symptoms.” And in the case of women with bipolar disorder, the same thing; “When I’m getting manic, these are the typical symptoms.” Then we have the discussion, “If I get depressed and it’s mild to medium, this is what I want.” It’s almost like an advanced directive. We say, yes, OK, we’ve talked about sertraline or something like that. I think that’s a good choice now. And I do this deliberately because I also make it a point to talk about ECT [electroconvulsive therapy] as being a particularly lifesaving and fetus-sparing treatment for severe depression late in pregnancy. People are often shocked, “What? You’re talking about ECT to a pregnant woman?” But actually, it’s a very safe treatment for severely ill women.

We talk about what treatments they would agree to now, when they’re well, should they become depressed, and also, in the case of bipolar disorder, what treatments they would like if they became manic. We discuss this over a couple of visits. The document is drawn up, and then I go through the formality of having the patient sign it, not because it’s really a legal document, but it’s a statement of commitment. And then I make sure that the partner has been brought into this discussion, and I make sure that the patient provides a copy to their primary care physician. And I keep a copy in my chart, so that it makes any future discussion of what to do not binding in any sense legally, but at least we’ve thought about it at a time when there wasn’t a pregnancy and there wasn’t any imminent crisis.

Andrew J. Cutler, MD: That’s fascinating, Sagar. I love the idea of being so proactive.

Transcript edited for clarity