A 32-year-old woman at 16 weeks gestation with no previous medical or psychiatric history comes to the office for a follow-up due to worsening depression. She says, "I don't understand why I feel this way since I was so happy to become pregnant and my fiancé is very supportive. Sometimes I start crying over nothing at all." The patient began seeing a therapist 8 weeks ago after her sister noticed that she seemed down. She had suicidal thoughts at that time, but has been able to control these by speaking with the therapist weekly. The therapy has helped somewhat, but the patient still feels depressed most of the day, has trouble sleeping, and wakes up early in the morning. She is also having trouble concentrating at work and has lost 2.5 kg (5.5 lb) over the past 4 weeks. She has no current suicidal or homicidal thoughts or psychotic symptoms.
Physical examination is unremarkable and laboratory studies, including complete blood count and TSH, are within normal limits.
Which of the following is the most appropriate treatment for the patient at this time?

Question

A 32-year-old woman at 16 weeks gestation with no previous medical or psychiatric history comes to the office for a follow-up due to worsening depression.  She says, "I don't understand why I feel this way since I was so happy to become pregnant and my fiancé is very supportive.  Sometimes I start crying over nothing at all."  The patient began seeing a therapist 8 weeks ago after her sister noticed that she seemed down.  She had suicidal thoughts at that time, but has been able to control these by speaking with the therapist weekly.  The therapy has helped somewhat, but the patient still feels depressed most of the day, has trouble sleeping, and wakes up early in the morning.  She is also having trouble concentrating at work and has lost 2.5 kg (5.5 lb) over the past 4 weeks.  She has no current suicidal or homicidal thoughts or psychotic symptoms.
Physical examination is unremarkable and laboratory studies, including complete blood count and TSH, are within normal limits.
Which of the following is the most appropriate treatment for the patient at this time?

Quizplus · Accepted Answer

This pregnant patient's depression is worsening despite psychotherapy, and her weight loss and impaired functioning should raise the physician's level of concern. Risks of untreated maternal depression include poor nutrition, nonadherence to prenatal care, impaired mother-infant bonding, and maternal suicide. Pharmacotherapy is indicated for mild to moderate depression that has not responded to psychotherapy or for moderate to severe depression as either monotherapy or in conjunction with psychotherapy. Severe antenatal depression marked by suicidal ideation or behavior, psychotic features, or marked inability to function requires inpatient hospitalization. Selective serotonin reuptake inhibitors (SSRIs) are first-line medications for antenatal depression; however, some (eg, sertraline) are better studied and have larger databases regarding safety and efficacy. With the exception of paroxetine (associated with a small increase in congenital cardiac defects), concerns about increased risk of cardiac malformations and developmental and neurobehavioral disorders associated with SSRI exposure have not been substantiated. Practice guidelines emphasize that the risks to the fetus and mother from untreated maternal depression generally outweigh the potential and unproven risks of treatment. However, clinicians must discuss the risks and benefits of treatment with patients to allow them to decide what is most beneficial. (Choice A) Electroconvulsive therapy is reserved for severely depressed pregnant patients who are quickly decompensating, require rapid treatment (eg, actively suicidal or homicidal, psychotic, not eating or drinking), or have failed several medication trials. (Choice B) Although this patient may benefit from increased frequency of therapy sessions, the severity of her depression, accompanying weight loss, and functional impairment make antidepressant treatment a priority. (Choices C and E) Serotonin norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine and the antidepressant mirtazapine appear to be safe for use in pregnant patients. However, they are generally used as second-line agents in patients who do not respond to an SSRI due to the greater availability of safety data with SSRIs. An exception would be a patient with a history of responding well to an SNRI or mirtazapine. Educational objective: Selective serotonin reuptake inhibitors are first-line treatment for pregnant patients with moderate to severe major depression or those who do not respond to psychotherapy alone. Physicians should discuss the risks and benefits of antidepressant treatment and untreated depression with patients to facilitate their decision-making. __________ References: Selective serotonin reuptake inhibitors in human pregnancy: on the way to resolving the controversy. (http://www.ncbi.nlm.nih.gov/pubmed/24321501) Treatment of mood disorders during pregnancy and postpartum. (http://www.ncbi.nlm.nih.gov/pubmed/20385337)

A 32-Year-Old Woman at 16 Weeks Gestation with No Previous