Treatment guidelines issued on depression during pregnancy

For women with serious conditions, medication may be the best route, but 'talk therapy' may alleviate suffering for others, according to a document prepared by two national physicians groups.

For the nearly one in four women who experience symptoms of depression during pregnancy, physicians on the front lines have long had little more than a prescription for antidepressants and a massive dose of uncertainty to offer.

The result: At last count, roughly 13% of pregnant women in the United States took antidepressant medications at some point in their pregnancy -- often with little to guide them in weighing the risks the drugs may pose to their fetus against the misery and dangers of untreated depression.

In a bid to resolve that conundrum, two of the nation's leading physicians groups have issued the first guidelines for the treatment of depression during pregnancy.

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What Should Count as a Mental Disorder in DSM-V?

If sick men fared just as well eating and drinking and living exactly as healthy men do . . . there would be little need for the science [of medicine].
attributed to Hippocrates

Well, while I’m here, I’ll do the work—and what’s the work? To ease the pain of living. . . .
Allen Ginsberg

What exactly is a “mental disorder”? For that matter, what criteria should determine whether any condition is a “disease” or a “disorder”? Is “disease” something like an oak tree—a physical object you can bump into or put your arms around? Or are terms like “disease” and “disorder” merely abstract, value-laden constructs, akin to “injustice” and “immorality”? Are categories of disease and disorder fundamentally different in psychiatry than in other medical specialties? And—by the way—how do the terms “disease,” “disorder,” “syndrome,” “malady,” “sickness,” and “illness” differ?

Anyone who believes there are easy or certain answers to these questions is either in touch with the Divine Mind, or out of touch with reality. To appreciate the complexity and ambiguity in this conceptual arena, consider this quote from the venerable Oxford Textbook of Philosophy and Psychiatry:



The term “mental illness” is probably best used for those disorders that are intuitively most like bodily illness (or disease) and, yet, mental rather than bodily. This of course implies everything that is built into the mind-brain problem!1(p11)

In a single sentence, we are already grappling with the terms “illness,” “disorder,” and “disease,” not to mention Cartesian psychology! And yet—daunting though these issues are—they are central to the practical task now before the DSM-V committees: figuring out what conditions ought to be included as psychiatric disorders.

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From Prevention to Preemption: A Paradigm Shift in Psychiatry

Universal prevention has been a focus of psychiatric research for the past 4 decades. Using a public health approach, research has shown that mitigating major risk factors, such as poverty and early life stress, and promoting protective factors can improve behavioral outcomes. In other areas of medicine, we have observed how similar preventive approaches have reduced deaths from cancer and infectious disease. By contrast, while reducing environmental stress and providing better maternal support improve general behavioral outcomes (by preventing the development of antisocial behavior, for example), there are few, if any, examples of preventive approaches in psychiatry that reduce either the morbidity or the mortality of our most disabling illnesses—such as schizophrenia and bipolar disorder.1,2

What can be done to improve the impact of preventive interventions in psychiatry? Do we have effective pre- ventions that are not being implemented? Or do we need new approaches
to reduce morbidity and mortality? While we certainly can do much more to implement what we already know, it may soon be time for us to consider a shift from universal prevention provided in the broad population to “preemptive” approaches. Preemptive interventions target those at greatest risk for mental illness and those with subdiagnostic signs or symptoms, and they provide what previously has been labeled “selective” and “indicated” prevention.3

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