Following a brief review of the consequences of untreated depressed mood and risks associated with antidepressant use during pregnancy, I comment on the evidence for complementary and alternative (CAM) modalities widely used to treat this serious problem.
Consequences of depressed mood and antidepressant treatment for the mother, fetus, and child
As many as 25% of women become depressed during pregnancy and relatively few receive adequate care resulting in potentially serious adverse outcomes for the mother, fetus, and child (Grote et al 2010). Depressed mood during pregnancy is associated with poor prenatal care including not taking prenatal vitamins and prescription medications and increased rates of alcohol and illicit substance abuse all of which can have negative health consequences for the mother and the fetus. Of great concern, the depressed mood in the perinatal period significantly increases the risk of maternal suicide.
Perinatal depression increases the risk of pre-term birth and low birth weight, both of which increase the risk of health problems in the newborn and long-term developmental problems. Infants of depressed mothers are more irritable, have more sleep problems, are at increased risk of delayed motor and cognitive development (Hanley and Ovelander 2012).
Both depressed mood and antidepressant use during pregnancy are associated with increased risk of medical problems in the fetus and, subsequently, behavioral problems in the child (Yonkers 2014). Both depressed mood in the mother and fetal exposure to antidepressants may increase the risk of having a miscarriage (Anderson et al 2014). A meta-analysis of seven studies found that fetal exposure to an SSRI in the third trimester (but not in early pregnancy) was associated with significantly increased risk of medical and behavioral complications in the newborn including respiratory distress, seizures, neurologic disorders, irritability, and problems nursing (Grigoriadis et al 2014). Antidepressant use in pregnancy may increase the risk of pre-eclampsia however findings are confounded by the increased rate of pre-eclampsia in depressed women who do not take antidepressants (Palmsten et al 2013).
Complementary and alternative approaches
Because of risks associated with antidepressants many pregnant women who are depressed prefer to use complementary and alternative (CAM) approaches. A recent review of CAM modalities widely used to treat depressed mood in pregnancy found some evidence for omega-3s, folate, and vitamin D, regular physical activity and yoga, but insufficient evidence for recommending S-adenosylmethionine, selenium, zinc, magnesium, and the B vitamins riboflavin, pyridoxine and cobalamin (Reza et al 2018).
The balance of this post is a concise review of the evidence for CAM modalities commonly used to treat depressed mood during pregnancy.
St. John’s wort (Hypericum perforatum) is widely used to treat depressed mood however the herbal may not be safe when taken during pregnancy because it interacts with several medications resulting in potentially negative health consequences. Many studies have established the antidepressant benefits of omega-3 essential fatty acids however studies on omega-3s in pregnant women report mixed findings. During pregnancy adequate dietary folate is essential for normal development of the fetal nervous system and pregnant women are advised to take folic acid daily. (Beydoun et al 2010). Daily folic acid supplementation may reduce the risk of depressed mood in pregnancy. Pregnant women with higher vitamin D levels are at reduced risk of depressed mood however findings of placebo-controlled studies are mixed (Spedding 2014; Gowda et al 2015). Although prenatal vitamins contain 400 IUs of vitamin D, a daily dose of 2000 IU may be needed to reach serum levels believed to be effective against depressed mood (Holick et al 2011). There is some evidence for antidepressant effects of selenium, zinc, and riboflavin however most studies are small and findings of placebo-controlled studies are inconsistent.
Other CAM modalities
Some depressed pregnant women who receive one hour of early morning full spectrum bright light exposure daily for at least three weeks reported significant improvements in mood however not all women respond to bright light therapy. Few studies have been done on acupuncture as a treatment of depressed mood during pregnancy and findings are mixed. Regular physical activity has established mood enhancing effects however only a few studies have been done on exercise for depressed mood in pregnancy and findings are mixed. Regular massage may have significant mood-enhancing effects and may also reduce the risk of premature birth. Regular yoga practice may reduce the severity of depressed mood in some cases but findings are inconsistent.
Because of the safety risks associated with antidepressant use during pregnancy many women are exploring a range of CAM modalities however for the most part research findings are mixed. The most appropriate treatment strategy for depressed mood during pregnancy depends on the severity of depressed mood, safety considerations for both the mother and the unborn fetus, and patient preferences. Depending on the unique factors in each case, the most prudent treatment regimen may include an antidepressant, one or more natural supplements, bright light exposure therapy, exercise, yoga, or a combination of modalities.