Treating antenatal depression

The principles of treating major depression during pregnancy are similar to those for the general population—see here. It is especially important to optimise psychosocial support during the perinatal period and adjust treatment with the following considerations.

If a patient with pre-existing depression becomes pregnant, emphasise the importance of effectively treating their depression and review the treatment plan—discuss pharmacological and psychological therapies; see Principles of treating major depression and Psychotropic use during pregnancy. Patients with pre-existing depression who become pregnant often stop pharmacological therapy because of perceived risk to the fetus. If the patient has a history of multiple or severe depressive episodes, avoid stopping effective therapy because of the high risk of relapse; patients with a history of severe or treatment-resistant depression will require a psychiatric opinion to guide management. If pre-existing depression worsens during pregnancy, see advice below.

If mild or moderate  depression develops during pregnancy, use psychological therapies as first-line treatment (eg cognitive behavioural therapy, interpersonal therapy, group therapy). Given the relatively short timeframe of pregnancy and the potential lag time for response to psychological therapies, also consider starting an antidepressant for moderate depression. Use a selective serotonin reuptake inhibitor (SSRI) other than paroxetine (sertraline is most commonly used)—see Antidepressant use during pregnancy and Approach to antidepressant therapy for major depression in adults and young people. If the patient intends to breastfeed, avoid starting fluoxetine during pregnancy because it has the highest reported concentrations, of all SSRIs, in breastmilk.

If new-onset severe depression develops during pregnancy, start a SSRI other than paroxetine (sertraline is most commonly used)—see Antidepressant use during pregnancy and Initial pharmacological treatment of major depression in adults. If the patient intends to breastfeed, avoid starting fluoxetine during pregnancy. If the patient is willing and able, also offer psychological therapies.

Treating (new or pre-existing) severe depression during pregnancy can be complex—if possible, refer to a specialist perinatal mental health service. Often a multidisciplinary team approach is required involving the usual treating clinician, a psychiatrist (preferably with perinatal expertise), the obstetric team and a paediatrician; electroconvulsive therapy (ECT) may be considered. Ideally, a patient with severe depression should give birth in a tertiary hospital with specialist neonatal care and a psychiatric team. If this is not possible, seek advice from the patient’s psychiatrist and a paediatrician.

For further information and support for clinicians and patients, see the Perinatal Anxiety and Depression Australia (PANDA) website. The PANDA National Helpline (1300 726 306) provides risk assessment, support, counselling and information (including referral advice about local medical, mental health and family services).

The Gidget Foundation Australia provides free telehealth counselling for parents in the perinatal period.