Pharmacotherapy or Untreated Antenatal Depression: A False Dichotomy

Pharmacotherapy or Untreated Antenatal Depression: A False Dichotomy

Sona Dimidjian, PhD, and Michael W. O’ Hara, PhD

Many depressed pregnant women struggle with the choice to take antidepressants or to remain untreated. This is a false choice. A large body of rigorous clinical research with depressed individuals in the general population demonstrates that psychotherapy is an efficacious treatment and a viable alternative to the options of no treatment or pharmacotherapy. Unfortunately, pregnant women have been excluded from much of this research.

The gold standard for determining the efficacy and safety of interventions is the use of randomized controlled trials (RCTs). RCTs are critical in allowing us to draw causal inferences about the efficacy of an intervention and to determine whether an intervention causes harm. In recent decades, we have witnessed a rapid increase in the number of RCTs testing the efficacy of psychotherapy for depression. Today, a range of psychotherapies have solid empirical support for the treatment of depression, including cognitive therapy,1 behavioral therapy,2 and interpersonal therapy.3 Other psychotherapies, such as mindfulness-based cognitive therapy, have support in the prevention of depression relapse.4,5 Researchers now are examining ways to make these treatments more robust and more transportable to a range of health care delivery systems.

Moreover, among general adult populations, we not only know that psychotherapy is efficacious, we also know that it is a viable alternative to pharmacotherapy. Multiple studies have tested directly the comparative benefits and risks of psychotherapy and pharmacotherapy for depression. In a recent placebo-controlled study conducted at the University of Washington,2 for example, we found that behavioral therapy demonstrated comparable outcomes to paroxetine, even among more severely depressed adults. In fact, there was no evidence of pharmacologic benefit among individuals with less severe major depressive disorder, results that were consistent with a previous RCT.6 We also have learned that psychotherapy offers enduring effects by preventing relapse after treatment is completed, whereas pharmacotherapy appears to offer protection only as long as patients continue treatment.7

There is an urgent need for more research on psychotherapy for depressed pregnant women. Pregnant women consistently report preference for psychotherapy and other nonpharmacologic approaches,8 and yet there is 1 published RCT testing psychotherapy among depressed pregnant women.9 One study does not constitute a viable evidence base to guide women and their health care providers in making well-informed treatment decisions.

Greater strides have been made recently in the study of postpartum depression. For example, a study underway at the University of Iowa and Brown University (ClinicalTrials.gov Identifier: NCT00602355) is comparing interpersonal psychotherapy with sertraline and placebo among postpartum depressed women. Results of this work are expected to inform women and their providers about the benefits and limitations of psychotherapy and pharmacotherapy for postpartum depression. Certainly, there are important ethical and pragmatic challenges to doing such comparative RCTs with pregnant women. However, there also are important ethical and pragmatic challenges to the widespread prescription of antidepressants antenatally10 in the absence of rigorously controlled data.

The management of depression during pregnancy requires weighing the risks and benefits of treatment to the woman and to her developing fetus. It is essential that we conduct research studies that rigorously test the full array of treatment options for depressed pregnant women. Research with depressed individuals at other points in the life cycle has demonstrated that psychotherapy is a viable alternative to pharmacotherapy. The need for such studies with antenatal populations is clear and pressing. The state of our science with antenatal populations must catch up to the breadth and rigor of research with other depressed populations. Pregnant women, their families, and their health care providers deserve no less.

References

1. DeRubeis RJ, Hollon S, Amsterdam J, et al. Cognitive therapy vs medications in the treatment of moderate to severe depression. Arch Gen Psychiatry. 2005;62(4):409-416. PubMed doi:10.1001/archpsyc.62.4.409

2. Dimidjian S, Hollon S, Dobson K, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. J Consult Clin Psychol. 2006;74(4):658-670. PubMed doi:10.1037/0022-006X.74.4.658

3. O’ Hara MW, Stuart S, Gorman LL, et al. Efficacy of interpersonal psychotherapy for postpartum depression. Arch Gen Psychiatry. 2000;57(11):1039-1045. PubMed doi:10.1001/archpsyc.57.11.1039

4. Teasdale JD, Segal Z, Williams J, et al. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J Consult Clin Psychol. 2000;68(4):615-623. PubMed doi:10.1037/0022-006X.68.4.615

5. Ma SH, Teasdale J. Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consult Clin Psychol. 2004;72(1):31-40. PubMed doi:10.1037/0022-006X.72.1.31

6. Elkin I, Gibbons R, Shea M, et al. Initial severity and differential treatment outcome in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. J Consult Clin Psychol. 1995;63(5):841-847. PubMed doi:10.1037/0022-006X.63.5.841

7. Hollon SD, Stewart M, Strunk D. Enduring effects for cognitive behavior therapy in the treatment of depression and anxiety. Annu Rev Psychol. 2006;57:285-315. PubMed doi:10.1146/annurev.psych.57.102904.190044

8. Dennis CL, Chung-Lee L. Postpartum depression help-seeking barriers and maternal treatment preferences: a qualitative systematic review. Birth. 2006;33(4):323-331. PubMed doi:10.1111/j.1523-536X.2006.00130.x

9. Spinelli MG, Endicott J. Controlled clinical trial of interpersonal psychotherapy versus parenting education program for depressed pregnant women. Am J Psychiatry. 2003;160(3):555-562. PubMed doi:10.1176/appi.ajp.160.3.555

10. Andrade S, Raebel M, Brown J, et al. Use of antidepressant medications during pregnancy: a multisite study. Am J Obstet Gynecol. 2008;198(2):194.e191-195.

Author affiliations: Department of Psychology, University of Colorado, Boulder (Dr Dimidjian) and Department of Psychology, University of Iowa, Iowa City (Dr O’ Hara). Financial disclosure: Dr Dimidjian has received grant/research support from the National Institute of Mental Health (NIMH). Dr O’ Hara has received grant/research support from NIMH and medication from Pfizer for a NIMH- supported clinical trial. Funding/support: None reported. Corresponding author: Sona Dimidjian, PhD, Department of Psychology, University of Colorado, 345 UBC, Boulder, CO 80309 ([email protected]).

doi:10.4088/JCP.09com05452

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