Part 1: Pre-Pregnancy Planning
This post is the first installment of a four part series. In this series, we will follow a patient from the pre-pregnancy planning phase to the postpartum period, and many key points discussed in previous blog posts will be reviewed. Please remember that every patient is different and this case should be viewed as one patient’s experience, rather than an outline of recommended treatment. Every patient must work with her own psychiatric provider to devise a plan that best suits her needs.
Ms. D is a 37-year-old married woman with a history of 4-5 episodes of depression since her college years. She also has a history of anxiety, including panic attacks. She came in for a pre-pregnancy consultation to discuss her options for treatment during pregnancy. At the time of the consultation, she stated that she wanted to become pregnant in the very near future.
Psychiatric History: As a young adult, she was treated with fluoxetine (Prozac) for about 2 to 3 years, which worked quite well for her. Other medication trials included sertraline (Zoloft) and escitalopram (Lexapro), but she did not feel they were effective. She also tried bupropion (Wellbutrin), but noted that she continued to have panic attacks. Lorazepam (Ativan), prescribed for anxiety, was also not helpful. While she did not remember the exact dosages of many of her medications, she stated that she typically has used antidepressants at the lower range of the recommended dosage.
She had been off medication for several years but restarted psychiatric medications about 6 years ago after a recurrence of her depression and anxiety. She was initially treated with fluoxetine for approximately 2 months, but she continued to have residual depressive symptoms and was eventually switched to venlafaxine ER (Effexor). Her symptoms resolved, and she remained well on venlafaxine ER 150mg for about 5 years without any symptoms of depression or anxiety.
At the time of consultation: In preparation for pregnancy, she stopped the venlafaxine abruptly without a taper and had significant withdrawal symptoms for approximately 3-4 weeks. She continued with weekly psychotherapy, and she remained off psychiatric medications for about 8 months before her symptoms of depression and anxiety returned. She restarted venlafaxine ER 150 mg, and her symptoms quickly improved, and after being on the medication for about 3 months, she presented for a pre-pregnancy planning consultation. At the time of the appointment, she noted that aside from some increased distractibility, she no longer had any symptoms of depression or anxiety.
Additional history: The patient denied a history of suicidal ideation, psychiatric hospitalization, or substance use issues. She denied any significant medical or surgical issues. She has had no previous pregnancies. There was no family history of psychiatric illness or substance use issues.
Ms. D was seen in consultation to discuss her treatment options during pregnancy. When reviewing the various options with this patient, there are multiple issues to consider.
Should Ms. D Maintain or Discontinue Her Antidepressant?
Given that she has a history of recurrent depression, Ms. D would be at risk for relapse if she were to come off her antidepressant. The risk is particularly high for Ms. D, as her last episode of depression was fairly recent, within the last year of the initial consultation, a relapse which followed the abrupt medication discontinuation. We have studies to show that there are high rates of relapse in women who discontinue their antidepressant proximate to conception and that rapid discontinuation of an antidepressant may increase her risk of relapse.
After coming off medication, Ms. D continued to receive weekly psychotherapy. While this may be the first intervention to consider for pregnant women with mild to moderate depression, it was not effective for her in terms of preventing a relapse.
What Medication is Best for Pregnancy?
Unfortunately there is sparse data regarding the use of venlafaxine in pregnancy and for that reason, it is typically recommended that patients switch to medications with better established reproductive safety profiles, such as the SSRIs, such as fluoxetine, citalopram, and sertraline. When she recently tried fluoxetine, she had a partial response. Other SSRIs, sertraline and escitalopram, were not effective.
The patient mentioned that she did not recall the dosages of medication she had taken in the past, but she recalled that they were on the lower side of normal. While one option might be remaining on venlafaxine during her pregnancy, she might also consider a re-trial of one of the SSRIs. It is possible that increasing the dose of one of these SSRIs may make the medication more effective for her.
Another factor to consider is the patient’s timeline for the planned pregnancy. This patient is 37 years old and expressed a desire to become pregnant in the very near future. Some patients, particularly younger ones, may be more amenable to changing medications prior to conception and holding off on pregnancy for a period of several months in order to determine how the new medication is working.
Betty Wang, MD
I have worked for 20 years as a Neonatal NP and three years ago became licensed as a Psych NP. I have seen many babies withdraw from SSRIs; however I have not really seen all the cardiac defects that have recently been published regarding use of SSRI’s in pregnancy. Can you advise?
Great case study…..I run into these type of life situations with my clients routinely as part of my practice in Maternal Mental Health. I refer them consistently to this blog and to http://www.otispregnancy.org, a group of teratogen specialists, to gather more data in order to inform their decisions after discussing this with their doctor or psychiatrist.
Very interesting information…thank you for the posting. I agree that there is a higher likelihood of relapse in women who discontinue their antidepressant regime; so caution is certainly prudent.
In addtion to psychotherapy; I was wondering if Ms. D had any regular routine of physical excercise in her lifestyle or utilized treatments such as “Therapeutic Massage” as an adjunct and enhancement to her depression/anxiety management plan ?
In my professional experience; Therapeutic Massage on a regular basis (at least every two weeks) can greatly benefit these patients. Thx!
I was about to turn 36 when I decided to try getting pregnant for the first time. I had a family history of bipolar disorder and had an approximately 25 year history of depression, with the past 15 years on medication. I tried stopping medication twice in the past and relapsed within 6 months each time. I had a lot of concerns and sought advice from many professionals about what I should do. I was frustrated by the amount of pre and peri-natal depression/ antidepressant information. I ultimately decided to remain on bupropion for my pregnancy. Other than delivering at 36 weeks, things went smoothly. I still worry that there will be some complication later in my son’s life because of the choice that I made, but I know I made the best decision that I could.
I am thrilled to see you’re doing this four-part study! I look forward to the next installment because I think many women struggle with the decision to stay on meds during pregnancy. It’s nice to see that there is more research being done on this topic. Thank you! Your website always has very relevant articles.
This is so exciting for me because I feel like I am in the same place as this woman. I had my first depressive episode 3 years ago and have tried multiple medications with varying effects. I got by for awhile until about 3 months ago when I had another episode of bad depression. As my symptoms are resolving, I am feeling more and more like I am ready to have a baby. I would prefer not to be on meds while I’m pregnant, but am so fearful. This information is very helpful for me. Thank you.
I enjoyed Part 1, received Part 3, but cannot get to Part 2. When it was emailed to me, it was blank. Can you help me?
Great series — nice balance of information, and the writing is accessible for patients as well as providers. I tweeted about it today.
@Krishna DasGupta, Yes! It is here: http://womensmentalhealth.org/posts/antidepressant-treatment-during-pregnancy-one-womans-experience-part-ii/
This is a brilliant series. There is very little information our there for women who suffer chronic depression and want to have a baby. While I am broadly in the same position as this woman, I also need IVF. It would be great to see more resources about women with chronic long term depression and their experiences of IVF. Keep up the good work!