Dr. Lee S. Cohen, Director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital, recently shared his insights on transcranial magnetic stimulation while pregnant with Ob.Gyn News on May 4th.
A growing number of girls ask about nonpharmacologic approaches for either the treatment of acute perinatal depression or for relapse prevention while pregnant.
The last several many years have brought an increasing level of comfort with respect to antidepressant use while pregnant, which derives from several aspects.
First, it’s been well described that there’s an increased risk of relapse and morbidity related to discontinuation of antidepressants proximate to pregnancy, particularly in women with histories of recurrent disease (JAMA Psychiatry. 2023;80[5]:441-50 and JAMA. 2006;295[5]:499-507).
Second, there’s an obvious increased confidence about using antidepressants while pregnant given the robust reproductive safety data about antidepressants with respect to each teratogenesis and risk for organ malformation. Other studies also fail to show a relationship between fetal exposure to antidepressants and risk for subsequent development of attention-deficit/hyperactivity disorder (ADHD) and autism. These latter studies have been reviewed extensively in systematic reviews of meta-analyses addressing this query.
Nevertheless, there are women who, as they approach the query of antidepressant use while pregnant, would favor a nonpharmacologic approach to managing depression within the setting of either a planned pregnancy, or sometimes within the setting of acute onset of depressive symptoms while pregnant. Other women are more comfortable with the information in hand regarding the reproductive safety of antidepressants and proceed antidepressants which have afforded emotional well-being, particularly if the road to well-being or euthymia has been a protracted one.
Still, we at Massachusetts General Hospital (MGH) Center for Women’s Mental Health together with multidisciplinary colleagues with whom we engage during our weekly Virtual Rounds community have observed a growing number of girls asking about nonpharmacologic approaches for either the treatment of acute perinatal depression or for relapse prevention while pregnant. They ask about these options for private reasons, no matter what we may know (and what we may not know) about existing pharmacologic interventions. In these scenarios, it is crucial to bear in mind that it isn’t about what we as clinicians necessarily find out about these medicines per se that drives treatment, but reasonably concerning the private calculus that ladies and their partners apply about risk and advantage of pharmacologic treatment while pregnant.
Nonpharmacologic treatment options
Mindfulness-based cognitive therapy (MBCT), cognitive behavioral therapy (CBT), and behavioral activation are therapies all of which have an evidence base with respect to their effectiveness for either the acute treatment of each depression (and perinatal depression specifically) or for mitigating risk for depressive relapse (MBCT). Several investigations are underway evaluating digital apps that utilize MBCT and CBT in these patient populations as well.
Latest treatments for which we’ve none or exceedingly sparse data to support use while pregnant are neurosteroids. We’re asked on a regular basis concerning the use of neurosteroids similar to brexanolone or zuranolone while pregnant. Given the information on effectiveness of those agents for treatment of postpartum depression, the query about use while pregnant is intuitive. But at this cut-off date, absent data, their use while pregnant can’t be beneficial.
With respect to newer nonpharmacologic approaches which have been checked out for treatment of major depressive disorder, the Food and Drug Administration has approved transcranial magnetic stimulation (TMS), a noninvasive type of neuromodulating therapy that use magnetic pulses to stimulate specific regions of the brain which have been implicated in psychiatric illness.
While there are not any safety concerns which have been noted about use of TMS, the information regarding its use while pregnant are still relatively limited, however it has been used to treat certain neurologic conditions while pregnant. We now have a small randomized controlled study using TMS while pregnant and multiple small case series suggesting a signal of efficacy in women with perinatal major depressive disorder. Unwanted side effects of TMS use while pregnant have included hypotension, which has sometimes required repositioning of subjects, particularly later in pregnancy. Unlike electroconvulsive therapy, (ECT), often used when clinicians have exhausted other treatment options, TMS has no risk of seizure related to its use.
TMS is now getting into the clinical arena in a more robust way. In certain settings, insurance firms are reimbursing for TMS treatment more often than was the case previously, making it a more viable option for a bigger variety of patients. There are also several exciting newer protocols, including theta burst stimulation, a brand new type of TMS treatment with less of a time commitment, and which could also be more economical. Nevertheless, data on this modality of treatment remain limited.
Where TMS matches in treating depression while pregnant
The actual query we’re getting asked in clinic, each in person and through virtual rounds with multidisciplinary colleagues from the world over, is where TMS might fit into the algorithm for treating of depression while pregnant. Where is it appropriate to be fascinated with TMS in pregnancy, and where should it perhaps be deferred at this moment (and where is it not appropriate)?
It might be of limited value (and possibly of potential harm) to change to TMS in patients who’ve severe recurrent major depression and who’re on maintenance antidepressant, and who consider that a switch to TMS might be effective for relapse prevention; there are simply no data currently suggesting that TMS could be used as a relapse prevention tool, unlike certain other nonpharmacologic interventions.
What about managing relapse of major depressive disorder while pregnant in a patient who had responded to an antidepressant? We’ve got seen patients with histories of severe recurrent disease who’re managed well on antidepressants while pregnant who then have breakthrough symptoms and inquire about using TMS as an augmentation strategy. Although we don’t have clear data supporting using TMS as an adjunct in that setting, in those patients, one could argue that a trial of TMS could also be appropriate – versus introducing multiple medicines to recapture euthymia while pregnant where the profit is unclear and where more exposure is implied by having to do potentially multiple trials.
Other patients with recent onset of depression while pregnant who, for private reasons, won’t take an antidepressant or pursue other nonpharmacologic interventions will ceaselessly ask about TMS. and the increased availability of TMS in the neighborhood in various centers – versus previously where it was more restricted to large academic medical centers.
I believe it’s a time of pleasure in reproductive psychiatry where we’ve a growing variety of tools to treat perinatal depression – from medications to digital tools. These tools – either alone or together with medicines that we’ve been using for years – are capable of afford women a greater variety of selections with respect to the treatment of perinatal depression than was available even 5 years ago. That takes us closer to a capability to make use of interventions that really mix patient wishes and “precision perinatal psychiatry,” where we are able to match effective therapies with the person clinical presentations and needs with which patients come to us.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at obnews@mdedge.com.