Transcription:
Treatment of Depression During Pregnancy: Balancing Disease Control and Medication Exposure

Melanie Cole: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And Joining me today is Dr. Katherine Wisner. She's the Director of the Asher Center for the Study and Treatment of Depressive Disorders and a professor of Psychiatry, Behavioral Sciences, and Obstetrics and Gynecology at Northwestern Medicine.

She joins me today to discuss the treatment of depression during pregnancy, balancing disease control and medication exposure. Dr. Wisner, thank you so much for joining us today. Give us a little background on the focus of your practice and your research.

Dr. Katherine Wisner: Yes. Hi, Melanie. Good to be here. My background of my research is in women's mental health with a specific focus on the treatment of mood disorders, such as depression and bipolar disorder as well as anxiety disorders during pregnancy and breastfeeding. And it's an important area because prevalence of mood and anxiety disorders in women is highest during those reproductive years.

Melanie Cole: Such an interesting topic we're discussing here today because I remember back during pregnancy and how easily it is to feel those feelings. So tell us about the scope of the issue. How common is it that women experience depression during pregnancy? And is there a difference as we look at the differences, Dr. Wisner, postpartum depression and baby blues, and we talk about those things all the time, during pregnancy? That type of depression, is it considered clinical depression? Are there different levels of it?

Dr. Katherine Wisner: Oh, yeah. All of what you said is true. So women's mental health and pregnancy is a major public health concern right now. And I'd like to just talk briefly about a study I did a couple of years ago where I screened 10,000 new mothers at four to six weeks postpartum with a depression screening measure. Fourteen percent of those women screened positive at four to six weeks after birth, that's one out of seven women. And the figure for the prevalence across the first postpartum year is about 20%. So this is a huge problem for our American mothers.

Now, those women who screen positive were more likely to be younger, African-American publicly insured, single and less well-educated. So in summary, less resources, less access to care, also was associated with higher rates of depression. And in those mothers who screened positive, about 20% of them reported thoughts of self-harm. When we did diagnostic interviews, the most common diagnosis was depression, so unipolar depressive disorder. And the majority of those women had anxiety disorders first in their lives and often those disorders begin in childhood. About 22% had bipolar disorders. And it's well known that the postpartum period is a high-risk time for the first manic or hypomanic episode, which is what defines bipolar disorders.

So again, the scope of the problem is just incredibly high and maternal mortality in the first year after birth in America is shameful. So in our most recent survey, the mortality rate for American women was 17.4 per 100,000 pregnancies, which was about 660 maternal deaths in 2018. We are among the lowest. There are two countries that are the lowest of industrialized countries in terms of maternal mortality and United States is one of them.

The maternal death rate for black women is two and a half times the ratio for white women and three times the ratio for women of Hispanic descent. A black mother with a college education has a 60% greater risk for maternal death than a white or Hispanic woman with less than a high school education. And my interest in this area is because, although the causes of death vary widely, the deaths from hemorrhage are very common around the time of birth. But deaths from heart conditions and mental health-related conditions, including substance use and suicide are the most common postpartum.

So the illnesses that I treat are responsible for a portion of the, again, shameful maternity mortality rate that exists in America. So there are a number of agencies trying to deal with this problem in America right now. And one of the things that I did with a group of investigators is what's called a Consensus Bundle on Maternal Mental Health for Perinatal Depression and Anxiety. And it's a guidance for maternity practices. And if anybody's interested, the PubMed number is 31135754.

Melanie Cole: Wow, Dr. Wizner. I can hear the passion in your voice when you discuss this topic and it is such a huge and complex topic. So tell us a little bit about some of the findings related to SSRI exposure and the impact on the fetus as you're telling us about the scope, the large scope of this issue in mental health issues. in pregnant women. Speak a little bit about the treatment options and why balancing that disease control is so monumental and medication exposure is of such concern.

Dr. Katherine Wisner: Yeah. So historically, we've been very concerned about medication exposure, such as antidepressants as well as other drugs and that results from, you know, the tragedy in the '60s and '70s from thalidomide. But over the last several decades, including a lot of the work that my team has done, we've also looked very carefully at the risks of exposure to disease. And certainly for the illnesses that we treat, depression, psychosis, anxiety disorders, those disorders affect a woman's whole body, her whole physiology.

The important thing to keep in mind is healthy mom, healthy baby. And that includes mental health as well. In fact, mental health is fundamental to have the ability to seek obstetrical care, to take care of herself, to eat appropriately, to manage her life in a way that prepares for the newborn.

So the illnesses that I see, depression and bipolar disorder again, psychosis, they're severe disorders that compromise not only a woman's ability to manage her pregnancy, but also her whole body's physiological processes as well. What happens to the mom certainly happens to the baby. So our concern about medications has gone from "Just stop all medications. They are bad for pregnant women," to "Wait a minute. We really need to think carefully about what are the effects of the disease."

And over the last decade, we have developed a number of important statistical analytic processes that allow us to separate out the effect of the underlying disease, the mental illness and all of the ramifications of mental illness from the medication itself. So sophisticated techniques now allow us to separate the effects of the drug that's always associated with the illness from the effects of the illness itself. And that literature has consistently shown that the negative effects of medication when used to treat these illnesses is not associated with the medication, but with all of the variables. Poverty, abuse, poor access to care, all of those variables that are associated with depression are really responsible for the adverse outcomes.

So we're now looking very carefully at what is the balance and how do we keep that mom mentally well in pregnancy. Now, there's the SSRIs and the SNRIs and the tricyclic antidepressants. None of them are contraindicated in pregnancy. And the general consensus now is that treating these illnesses is critically important for the maternal outcomes and for the fetal outcomes as well.

There are other treatments. Certainly, psychotherapy is an evidence-based treatment. We use bright morning therapy, which has a strong evidence base, not only for seasonal, but for non-seasonal depression as well. But the majority of women that we see in our academic-based program are already being treated with maintenance antidepressants and doing well on them. So frequently, they come in wanting to know what are the risks and benefits of continuing their medication across pregnancy and breastfeeding.

Melanie Cole: Wow. Isn't that so interesting, that you just said that antidepressants are not contraindicated in most cases during pregnancy. And what about fetal exposure to these medications? There's not really an issue, so that's why you're looking at this bigger picture of diversity and disparities and getting the mother help, non-drug maintenance, but that these types of medications are still okay.

Dr. Katherine Wisner: Yeah. The issue again is this balance. So when you said, "Well, there's no effect on the fetus," it is certainly the case that the fetus is exposed to that antidepressant. The other thing to remember is the fetus is exposed to the disease, to the anxiety, to the sleep disturbance, to the appetite disturbance or all of the physiological effects that mental illness has for that mother.

And in the studies that we've done, again we've been able to separate out can we treat the disease? Is the outcome for treating the disease in these women better or worse than not treating it? And the overwhelming amount of evidence is that treating the disease to keep the mom well and healthy, allow her to manage the pregnancy is critically important and that none of the effects that we were concerned about, that is preterm birth or other negative outcomes for the infant's length of gestation, say preterm birth weight, those things are related to the illness and they tend to be better when they're treated.

In fact, there's this Scandinavian study that showed that the rate of cesarean section and the rate of preterm birth were diminished in depressed women who were treated with antidepressants compared to those who were untreated. We don't have studies like that in America yet. But certainly, the overwhelming consensus is that we need to keep moms healthy for them to have healthy babies and that includes mental health as well.

Melanie Cole: It certainly does. So very said. As we wrap up, Dr. Wisner, what would you like other providers to be aware of when treating patients for depression during pregnancy and when do you feel that it's important that they refer to specialists like you at Northwestern?

Dr. Katherine Wisner: So the message I would have is I still hear about what I would consider this old essentially knee-jerk reaction that when a woman says, "Gee, you know, doctor, I am taking a medicine, I just found out I'm pregnant," that knee jerk reaction of stop all your medications when you're pregnant or breastfeeding puts women at risk for disease recurrence and has to be replaced by knowledgeable decision-making that balances the effects of the treatment with a control of the disease. And rather than make that kind of statement to a patient, "Stop all your medicines," particularly from mental illness, which can be devastating and again which contributes to that maternal mortality in America, please refer them for a consultation to our team.

Melanie Cole: Thank you so much, Dr. Wisner, for such an enlightening and informative episode. Absolutely wonderful. Thank you very much.

And to refer your patient or for more information, you can head over to our website at nm.org to get connected with one of our providers That wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please also remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.