Initiation of antidepressants in pregnancy
Kirby et al suggest general practitioners (GPs) should initiate antidepressant therapy for pregnant women with moderate to severe depressive illness, whilst they await psychiatric assessment (1). This is potentially harmful advice.
Most people diagnosed with depressive illness in primary care do not, in fact, have the disease at all (2) and do not require medication. Sadly, clinical accuracy will not be improved by the authors’ failure to state properly the cardinal diagnostic symptom: depressive episode is not characterised by “persistent low mood”(1), but by “depressed mood, to a degree that is definitely abnormal for the individual, present for most of the day and almost every day, largely uninfluenced by circumstances, and sustained for at least two weeks.”(3) In my experience, widespread use in primary care of diagnostic tools that largely ignore the various aspects of this clear description is the biggest reason for misdiagnosis.
The authors correctly identify the myriad potential risks to mother and child associated with antidepressant use in pregnancy. Consequently, their initiation should only be considered by a specialist, after a clear diagnosis has been reached by taking a careful history. With the best will in the world, a comprehensive discussion with the patient and her family on the possible risks and benefits of pharmacotherapy during pregnancy, weighed up alongside those of delaying treatment and of the faster-acting, more effective electroconvulsive therapy (4), cannot be adequately conducted by a GP during a ten-minute consultation.
A pregnant woman with a provisional diagnosis of moderate to severe depressive illness should be urgently referred for a psychiatric opinion, followed by active treatment within secondary care if indicated.
I beg to remain, Madam, your most obedient servant,
Dr Richard Braithwaite
1. Kirby N, Kilsby A, Walker R. Assessing low mood during pregnancy. BMJ 2019;366:l4584
2. Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 2009;374:589-99.
3. World Health Organisation (1993) The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. WHO.
4. UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003;361:799-808.
Competing interests: No competing interests