Mental health in pregnancy and after birth (SIGN)
Maternal use of antidepressants during the later stages of pregnancy has been associated with a neonatal adaptation syndrome and respiratory distress. Most cases of this are mild and transient, however, some affected infants require closer monitoring or neonatal intensive care.
Treatment with selective serotonin reuptake inhibitors (SSRIs) are recommended as the first-line choice for women prescribed antidepressant therapy for the first time in the perinatal period. For example, sertraline has good tolerability and is excreted in breastmilk in low levels. Where breastfeeding is preferred SSRIs with longer half life, such as fluoxetine, which may accumulate in breastmilk, should be used with caution, although this is not a contraindication to breastfeeding.
Mild-to-moderate depression
For women/birthing parents with persistent subthreshold depressive symptoms, mild or moderate depression in pregnancy or the postnatal period, consider alternatives to medication, such as facilitated self help or psychological intervention.
Women/birth parents with a history of mild-to-moderate depression who are currently taking a selective serotonergic reuptake inhibitor (SSRI), tricyclic antidepressant (TCA) or serotonin-norepinephrine reuptake inhibitor (SNRI) who become pregnant should consider stopping the medication gradually and engaging with facilitated self help.
For women/birthing parents with a history of moderate depression who become pregnant while taking an SSRI, TCA or SNRI, consider their previous response to treatment, risk of relapse, benefits, risks associated with medication and preference, and consider treatment options of switching to high-intensity psychological intervention or changing medication if there is a drug that is effective for her/them with a lower risk of adverse effects.
Severe depression
For women/birthing parents with a history of severe depression who present with initially mild symptoms of depression in pregnancy or the postnatal period, consider treatment with an SSRI, tricyclic antidepressant (TCA) or serotonin-norepinephrine reuptake inhibitor (SNRI) if they have expressed a preference for medication, decline psychological intervention or have symptoms that have not responded to a psychological intervention.
For pregnant women/birthing parents with severe depression, who are taking TCA, SSRI or SNRI, consider:
- continuing their current treatment
- changing medication if there is a drug that is effective with a lower risk of adverse effects
- combining medication with high intensity psychological intervention such as CBT, or
- switching to high intensity psychological intervention if they decide to stop medication.
Choice of medication
Before choosing a particular antidepressant for pregnant women/birthing parents, consider their past response to antidepressant treatment, obstetric history and any factors that may increase risk of adverse effects.
Before prescribing antidepressants to women/birthing parents who are breastfeeding, consider the infant’s health and gestational age at birth.
When prescribing antidepressants to women/birthing parents in the perinatal period consider SSRIs as first line pharmacological treatment for depression and/or anxiety.
Be aware that failure to use medication where indicated for moderate-to-severe depression and/or anxiety in pregnancy or postnatally may affect mother/birth parent-infant interaction, parenting, maternal/birthing parent health and wellbeing and infant outcomes.
Consider that infants exposed to medication in pregnancy may be at risk of neonatal adaptation syndrome and may require additional monitoring after birth. Monitoring should be individualised and considered as part of multidisciplinary birth planning taking into consideration the medication dose, polypharmacy and infant vulnerability such as risk of preterm delivery, low birth weight and any obstetric complications.
