Treatment decision-making for depression can be challenging given the wide array of pharmacologic and nonpharmacologic treatments available. Decisions are considerably more complex when depression occurs during pregnancy, because along with maternal well-being, fetal exposures to medication and untreated depression must be considered. More often than not, women do not engage in any treatment for antenatal depression. Some pregnant women may not seek treatment if symptoms are not recognized as depression. In other cases, stigma, decisional conflict, logistical barriers, or concerns about teratogenic effects may prevent care-seeking.

In reviewing risks and benefits regarding pharmacotherapy for maternal depression, Koren and Nordeng conclude “if their psychiatric condition necessitates pharmacotherapy,” benefits of prenatal antidepressant use outweigh risks of leaving antenatal depression untreated. For pregnant women interested in pharmacotherapy, or for those with chronic or severe depression, timely information about relative risks of antidepressant use is essential. However, how one defines a psychiatric condition as necessitating pharmacotherapy is critical. In the majority of cases, the decision need not be framed as to treat with antidepressants vs to not treat at all. For mild-moderate, nonchronic depression, other evidence-based depression treatments, such as cognitive-behavioral therapy and interpersonal psychotherapy, are clearly efficacious and presumably carry minimal or no risk to the developing fetus. The benefits of some forms of psychotherapy may in fact be longer-lasting than antidepressants. Major psychotherapies (cognitive-behavioral therapy, interpersonal psychotherapy) have been shown to be efficacious for treating perinatal depression in particular. Although not all patients have easy access to psychotherapy, and some may not be willing to try it, the low level of risk associated with psychotherapy–and its effectiveness–suggests pregnant women seen in various settings should be informed of psychotherapy as a viable treatment. Efforts to increase access to evidence-based psychotherapies are particularly important for this population, as are development and evaluation of new nonmedication-based interventions.

A patient-centered approach to decision making for antenatal depression treatment may be best accomplished not only by weighing risks and benefits of pharmacologic treatment as well as nonpharmacologic alternatives, but equally important, should involve a conversation with the patient regarding her preferences, values, and concerns about engaging in various treatments. Research indicates most pregnant women strongly prefer nonpharmacologic interventions. Soliciting patient preferences and openly discussing a range of alternatives for improving mood will increase likelihood that patients find a treatment that can be adhered to over time, thus improving outcomes for mother and child.