Antidepressant treatment falls short in pregnancy. (Maternal Depression).

WASHINGTON -- High scores on a depression rating scale showed that a significant proportion of women who were prescribed medication for depression during pregnancy were suboptimally treated, Dr. Irena Nulman reported at the annual meeting of the American Society for Clinical Pharmacology and Therapeutics.

The study included 141 women with depression who were enrolled in the Motherisk Program, a teratogen information service at the Hospital for Sick Children in Toronto.

The study was sponsored by the Canadian Institutes of Health Research and Novartis.

The women in the study were diagnosed with depression before pregnancy and reported having had depression for 1-12 years. A total of 77 women were being treated during the first trimester--or throughout pregnancy-with fluoxetine, while 64 women were taking a tricyclic antidepressant.

In addition, the study followed 42 pregnant controls, who were not believed to be depressed.

Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D), a visual analog scale that produces a score from 0 to 60, with a score of 16 considered a significant level of depressive symptoms. The scale has 100% sensitivity and 56% specificity, according to Dr. Nulman, associate director of Motherisk.

Fluoxetine doses ranged from 10 to 80 mg, and about two-thirds of the women were treated with 20 mg/day.

Among the 38 women taking fluoxetine during the first trimester only CESD scores ranged from 2 to 59, with a mean of 36.

The CES-D scores of women treated with fluoxetine throughout pregnancy were similar, ranging from 15 to 58, with only a handful of women scoring in the 15-17 range, Dr. Nulman reported at the meeting.

There was a negative correlation between the dosage used and the severity of symptoms: The most common dosage of fluoxetine was 20-40 mg/day, and all of the women who received a dosage in this range presented with serious depressive symptoms, she said at the conference.

All of the women on imipramine or amitriptyline, most of whom received 50-150 mg/day were seriously depressed as well, she added.

The study also showed that 16% of controls had scores in the depressed range, suggesting that a significant proportion of pregnant women may suffer from undiagnosed depression.

Because uncontrolled depression during pregnancy has been associated with an increased risk of adverse perinatal outcomes, "it is crucial to diagnose women of childbearing age with depression, and in light of the fetal safety of fluoxetine, to treat pregnant women with optimal doses," Dr. Nulman advised.

She and her associates have published studies documenting the safety of fluoxetine for the fetus.

Treatment of depression during pregnancy or breast-feeding "involves weighing the possible risks of fetal or infant exposure to a psychotropic medication" against the potential adverse effects of depression on the mother and child, she added.

Cognitive-behavioral therapy, psychotherapy and close follow-up also may be helpful.

Selective serotonin reuptake inhibitors should be the first-line treatment, because they are effective and nonteratogenic and have a lower risk of toxic effects, compared with other antidepressants, according to Dr. Nulman.