Common Mental Disorders Depression - New Zealand Doctor

Social networks appear to be an influential protective factor against postnatal
depression, 460 and there is also emerging evidence that peer support is effective
in reducing depressive symptoms in new mothers. 458 Women can be encouraged
to make use of natural support systems available from trusted family members and
friends and/or consider joining a community support group, such as a new mother
and baby group. The GDT notes that the establishment of voluntary peer support
groups and facilitated support groups for new mothers should be encouraged.
There is some evidence for the effectiveness of group exercise (eg, ‘pram walking’)
for women with depression in the postnatal period. 461
A woman with depression in the antenatal or postnatal period that does not respond
to initial treatment should be managed in consultation with maternal health services or
other appropriate psychiatric services.
Special issues: antidepressant use
There is a dearth of good evidence on the use of antidepressants in women who
are pregnant or breastfeeding. As this is an area in which new evidence is emerging,
recommendations on the safety of antidepressants during pregnancy may change
during the currency of these guidelines. Practitioners are encouraged to regularly
review practice in relation to prescribing antidepressant in this population, and to
consider seeking specialist advice when initiating antidepressant treatment for a
woman who is pregnant or breastfeeding.
Clinical management with antidepressants involves balancing competing risks
between mother and offspring. 455 Potential problems associated with withholding
antidepressants include the well-documented risks of untreated maternal depression,
which may seriously affect the mother, child and other family members. 101
Potential risks to the foetus/child associated with prescribing antidepressants include
congenital abnormality, spontaneous abortion, growth retardation, neonatal toxicity
or withdrawal effects and longer-term neurodevelopmental effects. 101 Risks to the
mother include overdose, medication side effects, and premature labour. 101
Antidepressants in pregnancy
The risks associated with antidepressants in the antenatal period vary according
to the stage of pregnancy. Any teratogenic effects are most likely to occur in the
first trimester, while exposure in the second and third trimesters is more likely to be
associated with toxic effects or effects on growth and functional development. 455
When antidepressants are the treatment of choice, selective serotonin reuptake
inhibitors (SSRIs), except paroxetine, are recommended as an appropriate firstline
therapy for most women. 453 Paroxetine should be avoided in pregnancy due
to teratogenic risk, in accordance with Medsafe advice. 462 Some practitioners may
recommend shorter-acting SSRIs such as citalopram or sertraline, but the longer half-
100
Identification of Common Mental Disorders and Management of Depression in Primary Care