Abstract
Nongravid individuals are known to be at high risk of having a relapse of depression if antidepressant therapy is discontinued. Pregnant women presumably are also at risk, despite the long held view of pregnancy as somehow protecting against psychiatric illness. This prospective study compared the risk of relapse in pregnant women who maintained or discontinued antidepressive drug treatment. The participants were 201 pregnant women cared for at centers expert in managing psychiatric disorders during pregnancy. All of them had a history of major depression before pregnancy, were at less than 16 weeks gestation, and had been euthymic for at least 3 months before the last menses. The women were currently receiving antidepressant therapy or had received it within 12 weeks before the last menstrual period.Participants were assessed using the Hamilton Rating Scale for Depression (HAM-D), the Structured Clinical Interview mood module for depression, and the Clinical Global Impressions Scale. The mean age at the first episode of depression was 19 years and the mean duration of depression exceeded 15 years. Just over half the participants had a current or past history of comorbid psychiatric illness—most often anxiety and eating disorders—and 44% reported 5 or more prior recurrent depressive episodes. More than 90% of women were receiving antidepressant therapy at baseline, most often with a selective serotonin reuptake inhibitor or a dual-action antidepressant.Relapse occurred in 68% of women who discontinued their antidepressant medication and in 26% who remained on treatment. Half of all relapses occurred in the first trimester and 90% by the end of the second trimester. The risk of relapse was 45% for women who increased their medication (most likely in response to increasing symptoms indicating impending relapse) and 35% for those who decreased it. Mean HAM-D scores were 23.7 and 20.8, respectively, for those who discontinued or maintained their medication. There were no suicide attempts during the study. The time to relapse was shorter in women who increased or stopped medication than in those who maintained or decreased treatment; 60% of women who discontinued their medication at the beginning of pregnancy restarted it.After adjusting for several possibly confounding factors, women who stopped treatment had a 5-fold increase in the risk of relapsing during pregnancy compared with those who maintained their medication. Women who reintroduced their medication after stopping it had a lesser risk of relapse, although they remained more vulnerable than those who did not alter their medication. The risk of relapse during pregnancy was increased in women who had been ill for longer than 5 years and in those having more than 4 episodes of recurrent depression.These findings suggest that pregnancy does not protect against a relapse of major depression. Affected women should be made aware of the risk of discontinuing their antidepressant medication during pregnancy.