Treating Depression during Pregnancy: Are We Asking the Right Questions?

Background: Major depressive disorder (MDD) is a common complication of pregnancy. Once the diagnosis of MDD is made, the physician must assist the pregnant woman in developing a treatment plan. Methods: In considering antidepressants, the benefit of medication treatment for maternal disease control must be balanced against the risk of the drug to the developing embryo-fetus. This is an individualized decision depending on the disease characteristics, likelihood of maternal depression response, probability of adverse fetal effects, and patient characteristics and values. Results: There is no “zero risk” solution in caring for the pregnant woman with MDD; both the disorder and the medication present risks to the mother and the embryo-fetus. If the decision to use antidepressant medication during pregnancy is made, the justification is that the disease is associated with greater risk than the treatment. The goal should be remission of symptoms to maximally reduce disease risk to the mother and developing fetus. Conclusion: Optimization of selective serotonin reuptake inhibitor dosing during pregnancy dictates several treatment goals: (1) the drug must be at the optimal dose for the woman; that is, the dose that produces the best response with tolerable side effects; (2) a continuous measure of symptoms must be repeated and adjustments to maintain optimal antidepressant efficacy may be required, due to pharmacokinetic changes during pregnancy; and (3) the resolution of pregnancy at birth also requires dose adjustment in accord with the woman's transition to the nonpregnant, breastfeeding state. Birth Defects Research 109:879–887, 2017.