Treatment​

Mild to moderate depression and anxiety

Consider psychotherapy

Cognitive-behavioral therapy (CBT)

• CBT is best administered by CBT-trained providers.
• Regularly monitor effectiveness and sustainability of treatment.

Interpersonal therapy (IPT)

• Refer the patient to an experienced counsellor.
• IPT is effective in women experencing problems with role transitions.

Consider biomedical intervention

Light therapy

• Light therapy is most effective for people with seasonal mood variation.
• Recommend a trial with commercially available light boxes.

Consider lifestyle and personal health interventions

Help the patient make lifestyle and personal health changes, including:

• increased support (i.e., help of partner, family and friends)
• nutritious meals – address any disordered eating
• sleep – suggest help with nighttime feedings
• hydration
• daily light exercise
• focus on personal time

Moderate to severe depression and anxiety

Consider pharmacotherapy

Ideally, pharmacotherapy should be accompanied by psychotherapy.

Table 17.1 summarizes information about dosages, off-label indications and risks.

Discuss fetal exposure to medications versus mental illness

• Tell the patient that no decision is risk-free.
• Explain that if the patient conceives while on antidepressant medication, the decision to discontinue medication must be weighed against a three to five times greater rate of relapse.
• Discuss warnings about neonatal withdrawal (Moses-Kokol et al., 2005), paroxetine (GlaxoSmithKline, 2005) and persistent pulmonary hypertension of the newborn (Chambers et al., 2006). Focus on study merits versus methodological challenges:
  • Long-term studies up to six years of age show no cognitive effects of in utero exposure to SSRIs.
  • Exposure to persistent postpartum depression is associated with delayed language and cognitive development.
  • Treating maternal depression and anxiety helps to prevent these outcomes in children.
• Help the patient make an informed decision without bias.

Inform patients

The primary care provider should inform patients:

• of placental transfer of medication
• to continue nursing on the same medications used in pregnancy
• of excretion of medication into breast milk, which is generally negligible. A physician should monitor the breastfed infant.

Choice of pharmacotherapy

• No specific pharmacotherapy is "the best."
• Pharmacotherapy that has been effective in the past is likely to work again.
• Recommend pharmacotherapy that has been effective for the patient's family members.
• Check for interactions with other medications.
• Perinatal patients often fail to respond to antidepressants alone.
• Augmentation with other medications, including antipsychotics, is useful for patients who do not respond to antidepressants.
• Use benzodiazepines for no more than two weeks to stabilize extreme anxiety.
• Patients vary in response time and dose.

Compliance and discussion of side-effects

• Inform the patient that the most common side-effects – mild headache and GI upset – usually abate within one to two weeks.
• Advise the patient to avoid alcohol.
• Explain that alternative therapies (e.g., St. John's wort) may adversely interact with medications.
• Advise against abrupt discontinuation of medication. Slow taper is recommended.

Dose adjustment in pregnancy and postpartum

• Watch for mood changes in the late second and early third trimester.
• Dose increase may be required as plasma volume and hepatic metabolism change.

Duration of treatment

• For a single episode of depression, continue treatment for one year.
• Recurrent depressive episodes will likely require much longer-term maintenance therapy.

Psychosis and suicidality

Consider the following in acutely suicidal or psychotic pregnant and postpartum patients and explain the pros and cons to family members:

• emergency psychiatric consultation
• hospitalization
• ECT

Adjunctive measures

• Lifestyle and personal health interventions 
• Couples counselling
• Addiction medicine
• Educational support groups

Child protection issues

• Be especially aware if there is ongoing abuse of alcohol or other drugs in the home.
• You must alert the appropriate ministry immediately if you suspect harm, through neglect or abuse, being done to a child.
• Make every effort to establish a rapport of safety. Many women are terrified of their babies being taken away from them and this feeds into their anxiety.
• Emphasize that the goal is to restore the woman to a position where she can care for her child.

Pre-pregnancy consultation

• Evaluate the patient's current mood state.
• Assess carefully whether depression is likely to occur in future pregnancies.
• Review treatment options based on the severity and frequency of symptoms.
• Discuss the possibility of medications in pregnancy.
• Assess safety on a case-by-case basis.
• Always invite the woman's partner to participate.