Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment.
Cohen LS, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, et al.;
Commented by , 20 Feb 2006
Background
It is a widely held contention that pregnancy is a time of well-being and that pregnancy protects against depression. Antidepressant pharmacological treatment is often discontinued prior to or initially during pregnancy, but is has not been investigated how this affects the risk of relapse of depression.
Method
The study was a prospective naturalistic study including a total of 201 pregnant women from three centres with specific expertise in the treatment of psychiatric disorders during pregnancy.
Participants were included in the study if they had a history of major depression prior to pregnancy, were currently euthymic for a period of at least three month prior to pregnancy and were currently or recently receiving antidepressant treatment.
The aim was to compare time to relapse of depression according to DSM-IV criteria among women who chose to discontinue treatment with time to relapse among women who chose to maintain treatment with medication.
Most women were treated with SSRIs or SNRIs. Depressive symptoms were assessed every month.
Results
Among the 201 women included in the study, 86 (43%) experienced a relapse of major depression during pregnancy. A total of 54 women dropped out of the study due to abortion and other causes.
A total of 65 women chose to discontinue treatment proximate to conception whereas 82 maintained treatment. The rate of relapse of major depression was substantially and significantly higher among women who discontinued treatment (68% versus 26%, hazard ratio: 5.0 (95% CI: 2.8-9.1)).
The rate of relapse was greatest during first and second trimester.
Professor Kessing's comments
This is an urgently needed study. The results clearly show that discontinuation of antidepressant treatment proximate to conception substantially increases the rate of relapse of major depression and further that this rate of relapse is as high as during non-pregnancy.
There are two important methodological caveats that have to be considered. Firstly, the study was not a randomised controlled study, which for ethical reasons may be hard to undertake. However, the authors adjusted for relevant demographic and clinical differences between the two groups.
Secondly, the findings may not be generalized to women with single depressive episodes or moderate depression as 76 % of the sample had three or more prior depressive episodes and the vast majority had a family history of depression.
Nevertheless, the results are important when women with recurrent depression are guided about antidepressant treatment during treatment. In general, major congenital malformations has not been found to be associated with exposure to older or newer antidepressants although recent warnings has been raised against prenatal treatment with paroxetine.
The present study emphasises that the risk to the mother is substantial when discontinuing treatment and this information may add to change the indication for prophylactic treatment during pregnancy.