The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists.

OBJECTIVE: To address the maternal and neonatal risks of both depression and antidepressant exposure and develop algorithms for periconceptional and antenatal management. METHOD: Representatives from the American Psychiatric Association, the American College of Obstetricians and Gynecologists and a consulting developmental pediatrician collaborated to review English language articles on fetal and neonatal outcomes associated with depression and antidepressant treatment during childbearing. Articles were obtained from Medline searches and bibliographies. Search keywords included pregnancy, pregnancy complications, pregnancy outcomes, depressive disorder, depressive disorder/dt, abnormalities/drug-induced/epidemiology, abnormalities/drug-induced/et. Iterative draft manuscripts were reviewed until consensus was achieved. RESULTS: Both depressive symptoms and antidepressant exposure are associated with fetal growth changes and shorter gestations, but the majority of studies that evaluated antidepressant risks were unable to control for the possible effects of a depressive disorder. Short-term neonatal irritability and neurobehavioral changes are also linked with maternal depression and antidepressant treatment. Several studies report fetal malformations in association with first trimester antidepressant exposure but there is no specific pattern of defects for individual medications or class of agents. The association between paroxetine and cardiac defects is more often found in studies that included all malformations rather than clinically significant malformations. Late gestational use of selective serotonin reuptake inhibitor antidepressants is associated with transitory neonatal signs and a low risk for persistent pulmonary hypertension in the newborn. Psychotherapy alone is an appropriate treatment for some pregnant women; however, others prefer pharmacotherapy or may require pharmacological treatment. CONCLUSIONS: Antidepressant use in pregnancy is well studied, but available research has not yet adequately controlled for other factors that may influence birth outcomes including maternal illness or problematic health behaviors that can adversely affect pregnancy.

Suicide in pregnancy.

BACKGROUND: Pregnant women with bipolar disorder often elicit conflicts between maternal and fetal considerations. CASE: A 26-year-old primigravida at 12 weeks' gestation presented for emergency psychiatric evaluation after discontinuing psychotropic medications when starting prenatal care. She developed worsening depression and was suicidal. She was admitted to an inpatient psychiatric unit, medication was reinitiated, and she appeared to stabilize well enough to be followed as an outpatient. Two days after discharge, she shot herself in the left chest, resulting in her death and that of her fetus. CONCLUSION: When choosing to maintain or discontinue mood stabilizers during pregnancy, decisions are best made by the use of a risk-benefit model that takes into account the health and well-being of both mother and fetus.

Dementia presenting as postpartum depression.

BACKGROUND: Other conditions that can mimic postpartum depression are rare but must be considered. CASE: A 37-year-old woman developed mood symptoms as well as progressive hyperphagia, hypersexuality, disinhibition, and impairment of judgment after delivery of her third child. She was unresponsive to multiple treatments for depression and was evaluated for frontal lobe syndromes. CONCLUSION: Frontotemporal dementia, formerly known as Pick disease, is a primary degenerative dementia for which no cause is clearly established. Family history or genetic abnormalities are found in about 50% of cases. The diagnosis is frequently missed or delayed, as in this case, because it occurs in a younger age group, presents with unusual signs and symptoms, and is far less prevalent than Alzheimer disease.