A pregnant 28-year-old woman with recurrent major depression that has been kept in remission with antidepressants is uncertain about how to manage her depression during the pregnancy.
“Ms. G,” a 28-year-old married woman in her ninth week of a planned pregnancy, has symptoms of general anxiety about her pregnancy, panic attacks, sleep disruption, fatigue, and loss of appetite with nausea and vomiting. She denies feeling sad, as she is excited about her pregnancy. Her interest in her work and hobbies has declined, but she attributes this to the exhaustion of her first trimester. She has been referred for consultation regarding treatment of her depression during her pregnancy, as her obstetrician is concerned about the severity of her current symptoms in light of her history. Her obstetrician had recommended that Ms. G discontinue her medication before she became pregnant, but she chose not to do so out of fear that her symptoms would recur.
Ms. G has a history of recurrent major depression. She received intermittent supportive psychotherapy over the years when in crisis but has relied primarily on medication to keep her depression in remission. She was treated by psychiatrists from the age of 16, when she experienced her first severe depression, until age 24, when her illness went into stable remission with a combination of sertraline (150 mg/day) and clonazepam (0.5 mg, twice daily as needed for anxiety). For the past 3 years, she has been treated by her primary care physician, as she has not required any medication changes other than brief increases in her anxiolytic during her wedding planning and times of travel. She cannot recall all of the medications she has taken in the past but does recall poor response to or side effects from fluoxetine, paroxetine, lithium, lorazepam, bupropion, and venlafaxine. She had two hospitalizations during high school after serious suicide attempts.
She and her husband decided to try to conceive, as she was euthymic, was in a stable relationship, had a stable job, and had some family support. She has no significant medical history except exercise-induced asthma. She experienced a first-trimester miscarriage 18 months ago. Her family history is significant for a mother with obsessive-compulsive disorder who experienced severe depression after the birth of her first two children (the patient’s older siblings). The patient’s mother died at age 55 from breast cancer when the patient was 22 years old. The patient did not know her father. Her two older siblings are healthy except for alcoholism (her brother) and anxiety (her sister).
Ms. G. has multiple questions. She learned of her pregnancy through a home pregnancy test 1 week after she missed her period. She immediately discontinued the clonazepam, which she had not been using often. Although her obstetrician recommended that she discontinue the sertraline, she was not prepared to do so; as a compromise, she decreased her dosage by 25 mg every 4 days to 75 mg. Now, at 9 weeks, she is concerned about having another miscarriage and wants to know what impact the medication will have on the fetus. She is also concerned that her depression will return if she discontinues the medication completely. How do you guide her and her providers?