Pregnancy and the postpartum period is a time of increased risk for depression.  Therefore, women who are treated with antidepressant medications must consider whether or not to stay on medication during pregnancy.  Despite reassuring data regarding the reproductive safety of various antidepressants, a woman may prefer not to continue medication during pregnancy due to concerns about long term effects of medication on the baby.  However, by discontinuing antidepressant medication, a woman increases her risk of depression during pregnancy.  This is a highly personal decision for women as the potential risks of continuing medication must be weighed against the possibility of relapse and the potential effects of untreated depression on the pregnancy and baby.

When making this decision, it is not uncommon for women to want to “strike a compromise”, to reduce the dose of medication with the hope that this will reduce the exposure of the fetus to medication while continuing to stay well.  A reduction in dose, however, may increase the risk of relapse.

Current guidelines suggest that depression be treated to remission, a point where symptoms are minimal or no longer present.  The more residual symptoms that are present after treatment, the higher the risk for relapse.  During pregnancy, as at other times, a woman’s depression should be treated aggressively in order to achieve remission.

In order to minimize the risk of relapse, the American Psychiatric Association Consensus Guidelines recommend that patients continue on the dose of medication that helped to treat the initial depression through the continued phases of treatment.  While reducing ones dose of medication after achieving remission of symptoms has not been adequately studied, the limited data we have on the subject suggests that lower doses increase the risk for relapse.

While the effects of lower antidepressant doses on depressive relapse in pregnancy has not been studied, our knowledge of the treatment of depression in general leads us to advise most women taking antidepressant medications during pregnancy to stay at the dose of medication that has treated their depression in the past.  A lower dose of medication provides no known reduction in risk to the fetus and likely increases the woman’s risk of developing depression during pregnancy or the postpartum period.

Furthermore, there is data to indicate that during pregnancy enhanced drug metabolism may lead to lower serum levels of antidepressants, particularly during the second half of pregnancy; this has been observed with both SSRIs (Sit et al, 2008) and tricyclic antidepressants (Wisner et al, 1993).  While we do not necessarily recommend increasing antidepressant dosages without clinical need, it should be noted that lowering the antidepressant dosage during pregnancy, in combination with these metabolic changes, may lead to significant decreases in serum levels of antidepressant, thus increasing the risk of relapse.  During pregnancy, careful monitoring for depressive symptoms is indicated and an increase in antidepressant dosage should be considered if recurrent symptoms emerge.

Women who choose to stay on antidepressant medications during pregnancy would best protect themselves from a relapse of depression by continuing at a dose that helped achieve remission from depressive symptoms initially.  Additionally, augmenting treatment with other stress reduction methods can play an important in maintaining good mental health.

Julia Wood, MD

American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2006. American Psychiatric Association

Cohen LS, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera AC, Suri R, Burt VK, Hendrick V, Reminick AM, Loughead A, Vitonis AF, Stowe ZN.  Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 2006 Feb 1;295(5):499-507.

Shelton RC. Long-term management of depression: tips for adjusting the treatment plan as the patient’s needs change. J Clin Psychiatry. 2009;70 Suppl 6:32-7.

Sit DK, Perel JM, Helsel JC, Wisner KL. Changes in antidepressant metabolism and dosing across pregnancy and early postpartumJ Clin Psychiatry. 2008 Apr;69(4):652-8.

Wisner KL, Perel JM, Wheeler SB. Tricyclic dose requirements across pregnancy. Am J Psychiatry. 1993 Oct;150(10):1541-2.