DEPRESSION AND OTHER MOOD DISORDERS Mood disorders include depression, bipolar disorder, and anxiety disorders. Selective serotonin reuptake inhibitors (SSRIs, such as paroxetine or sertraline) or serotonin and norepinephrine reuptake inhibitors (SNRIs, such as venlafaxine or duloxetine) are often prescribed for primary care management of depression and other mood disorders.
When SSRIs or SNRIs are not fully effective, clinicians may refer patients to mental health specialists for consultation and possible ongoing management. Women of reproductive age who receive specialty care for mood disorders are encouraged to continue their regular visits to primary care clinicians.
Medication: Risk for birth defects Anticonvulsants, such as valproate, carbamazepine, and lamotrigine, are commonly used to treat bipolar disorder.23 When taken during the first trimester of pregnancy, these drugs pose well-documented risks to the rapidly developing fetus. Most evidence relates to the risk for neural tube defects, such as spina bifida, but other evidence suggests a risk for general cognitive impairment after prenatal valproate exposure. While the latter is based primarily on studies of women taking anti-epileptic drugs for seizure control—not psychiatric diagnoses—first-trimester risks appear to be independent of maternal seizures.23 Although folic acid supplementation decreases the incidence of neural tube defects (see discussion under “Nutritional Deficiencies"), it is unknown if such supplementation is effective in mitigating the additional risks to the fetus from exposure to anticonvulsants.
Female patients of childbearing age must be advised of the potential effects of these commonly prescribed mood-stabilizing drugs, not only as they relate to the diagnosis being treated but also regarding their possible effects on an early, undiagnosed pregnancy. Unfortunately, evidence indicates that insufficient attention is given to counseling reproductive-age women about the risks and benefits of these drugs as they relate to potential conception, at least in the context of specialty care.23 Therefore, the primary care clinician and the specialist should utilize a team approach, emphasizing careful reproductive planning to avoid pregnancy while under treatment with these drugs to ensure the best possible outcomes.
In the context of potential pregnancy, the need to manage depression and other mood disorders effectively is particularly important: Prepregnancy depressive mood has been significantly associated with preterm birth, and at least 14.5% of women experience a new episode of depression during pregnancy.24 Thus, effective treatment of mood disorders should be a priority, both as part of preconception care and during pregnancy.
Similarly, treatment strategies for postpartum depression—widely estimated to affect 10% to 20% of new mothers—must consider the potential risks of pharmacologic therapy to a fetus should the patient conceive during treatment.
