TMS Therapy for Depression During Pregnancy

(Article originally published Sept 16, 2011)

Risks of Clinical Depression During Pregnancy:

Up to 23% of expectant women either enter pregnancy already suffering from a major depressive episode, or become clinically depressed during their pregnancy.[i] Ongoing depression during pregnancy is associated with negative maternal and fetal outcomes. Women who are depressed and pregnant often do not eat properly, cannot sleep, and become excessively irritable, overwhelmed, and anxious. Furthermore, being depressed and pregnant substantially increases the risk of postpartum depression.[ii] Maternal depression also increases the risk of low birth weight,[iii] developmental delay and neurobehavioral difficulties.[iv],[v],[vi] Children of depressed mothers are more likely to have conduct problems and emotional instability, and are at increased risk of requiring psychiatric care [vii] ,[viii],[ix]

Because the risks of clinical depression are substantial, it is important to seek professional care. The risks of antenatal maternal depression must be carefully balanced against the risk of various potential treatments in pregnancy, for both maternal and fetal health.

Treatment Options for Depression During Pregnancy:

A number of treatment options for pregnant women suffering from depression are available. For mild cases of clinical depression during pregnancy, often psychotherapy can be sufficient treatment. For depressions that are moderate or severe, psychotherapy is often inadequate, and antidepressant medications are frequently employed.

For very acute, severe and life-threatening cases of depression during pregnancy, electroconvulsive therapy (ECT), under the auspices of both a psychiatrist and an obstetrical anesthesiologist, can be effective.

Over the past few years, however, an increasing number of conflicting studies have been published that suggest that maternal use of antidepressant medications, especially selective serotonin reuptake inhibitors (SSRI), may be riskier than once believed. After completing a comprehensive clinical evaluation, an experienced reproductive psychiatrist is able to weigh the risks of antidepressant medication use during pregnancy against the risks of clinical depression for both maternal and neonatal wellbeing. If the patient’s personal and family history and symptoms of depression are substantial, the benefits of medication may out-weigh risks of medication.

TMS Therapy for Depression: A New Alternative for Treating or Preventing Depression During Pregnancy:

Transcranial Magnetic Stimulation (TMS), the use of magnetic pulses to stimulate specific areas of the brain that are associated with depression, may be an option in cases where non-invasive, non-systemic treatment for depression during pregnancy is preferred or indicated. To completely avoid medication exposure to the developing fetus during pregnancy, TMS can be used as monotherapy. In more complicated cases, TMS may also be employed as an augmentation treatment instead of adding a second or third drug to address more resistant depressions during pregnancy.

While the safety and effectiveness of TMS Therapy has not yet been established in pregnant patient populations through a controlled clinical trial, preliminary data suggest that TMS may pose significantly less risks in pregnancy than medication use.

During TMS therapy for depression, the magnetic field produced by the FDA-approved NeuroStar TMS device does not emit any ionizing (x-ray) or radiofrequency (cell phone) radiation, nor does it affect any areas below the shoulder.[x] Furthermore, unlike medication, the magnetic pulses released by the TMS machine do not enter the bloodstream to expose a developing in-utero baby, which is also reassuring. Recently, an open-label pilot study showed that 7 out of 10 pregnant patients responded to TMS therapy for depression, with no negative pregnancy outcomes.[xi] Other case reports also show promising results.[xii],[xiii],[xiv]

Of course, women of childbearing age with depression who wish to become pregnant are best advised to be stabilized prior to conception. It is estimated that close to 70% of pregnant women with a history of depression who discontinue their antidepressants relapse.[xv] Optimally, therefore, a woman should enter pregnancy having already been successfully treated for depression to complete remission. Thus, women who are treated with TMS for depression should ideally be followed for a period in order to ensure stability and continued remission, prior to attempting conception. If some depressive symptoms return during pregnancy after a history of successful TMS treatment, then booster TMS treatments can be effective.

Nevertheless, although it is best to plan ahead with TMS treatment in order to be free of depression prior to pregnancy, TMS may be a viable alternative to antidepressant medications or augmentation agents during pregnancy.

Many Treatment Options for Women Suffering from Depression During Pregnancy:

Clinical depression, if left untreated, can pose serious risks to both mother and baby. While the risk-benefit analysis needs to be carefully assessed in each individual case before deciding on a particular treatment, many treatment options are available, including psychotherapy, medication, ECT, and now TMS, a new non-systemic, non-invasive option for the treatment of depression during pregnancy.

[i] Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:703-13. http://www.ncbi.nlm.nih.gov/pubmed/19701065

[ii] Miller LJ: Postpartum depression. JAMA 287:762-765, 2002. http://www.ncbi.nlm.nih.gov/pubmed/11851544?dopt=Abstract

[iii] Steer RA, Scholl TO, Hediger ML, Fischer RL: Self-reported depression and negative pregnancy outcomes. J Clin Epidemiol 1992;45(10):1093-9.http://www.ncbi.nlm.nih.gov/pubmed/1474405

[iv] Zuckerman B, Bauchner H, Parker S, Cabral H. Maternal depressive symptoms during pregnancy, and newborn irritability. J Dev Behav Pediatr 1990;11:190-4. http://www.ncbi.nlm.nih.gov/pubmed/2212032

[v] Deave T, Heron J, Evans J, Emond A: The impact of maternal depression in pregnancy on early childhood development. BJOG: 2008:115:1043-51.http://www.ncbi.nlm.nih.gov/pubmed/18651886

[vi] Field T, Diego M, Hernandez-Reif M, Schanberg S, Kuh C, Yando R, Bendell D. Pregnancy anxiety and comorbid depression and anger: effects on the fetus and neonate. Depression and Anxiety. 2003;17:120-51. http://www.ncbi.nlm.nih.gov/pubmed/12768648

[vii] Weissman M, Prusoff B, Gammon G, Merikangas K, Leckman J, Kidd K. Psychopathology in the children (ages 6-18) of depressed and normal parents. J Am Acad Child Psychiatry 1984;23:78-84. http://www.ncbi.nlm.nih.gov/pubmed/6693680

[viii] Lyons-Ruth K, Wolfe R, Lyubchik A. Depression and the parenting of young children: making the case for early preventive mental health services. Harv Rev Psychiatry 2000;8:148-5. http://www.ncbi.nlm.nih.gov/pubmed/10973939

[ix] Weismann MM, Pilowsky DJ, Wickramarante PJ et al. Remissions in maternal depression and child psychopathology, a STAR*D-child report. JAMA 2006;295:1389-98. http://www.ncbi.nlm.nih.gov/pubmed/16551710

[x] Confirmed by Neuronetics Medical Affairs on Aug 8, 2011.

[xi] Kim, D, et al. An open label pilot study of transcranial magnetic stimulation for pregnant women with major depressive disorder. J of Women’s Health. Volume 20, Number 2, 2011. http://www.ncbi.nlm.nih.gov/pubmed/21314450

[xii] Dongjun Zhang and Zeqing Hu. RTMS may be a good choice for pregnant women with depression. Archives of Women’s Mental Health. Published online: 24 February 2009. http://www.ncbi.nlm.nih.gov/pubmed/19238519

[xiii] Tan O, et al. Antidepressant effect of 58 sessions of rTMS in a pregnant woman with recurrent major depressive disorder: a case report. Primary Care Companion. J Clin Psychiatry. 2008;10(1) 69-70. http://www.ncbi.nlm.nih.gov/pubmed/18311426

[xiv] Nahas Z et al. Safety and feasibility of repetititve TMS in the treatment of anxious depression in pregnancy. J Clin Psychiatry. 1999;60:50-52.http://www.ncbi.nlm.nih.gov/pubmed/10074879

[xv] Cohen LS, Altshuler LI, Harlow BI, Nonacs R, Newport DJ, Viguera AC, Suri R, Burt VK, Hendrick V, Reminick AM, Laughed A, Vinton’s, AF, Stowe ZN. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 2006;295:499-507.http://www.ncbi.nlm.nih.gov/pubmed/16449615