Risk-benefit decision making for treatment of depression during pregnancy

Objective: The Committee on Research on Psychiatric Treatments of the Ameri can Psychiatric Association identified treatment of major depression during pregnancy as a priority area for improvement in clinical management. The g oal of this article was to assist physicians in optimizing treatment plans for childbearing women. Method: The authors' work group developed a decision-making model designed to structure the information delivered to pregnant women in the context of the risk-benefit discussion. Perspectives of forensic and decision-making e xperts were incorporated. Results: The model directs the psychiatrist to structure the problem throug h diagnostic formulation and identification of treatment options for depres sion. Reproductive toxicity in five domains (intrauterine fetal death, phys ical malformations, growth impairment, behavioral teratogenicity, and neona tal toxicity) is reviewed for the potential somatic treatments. The illness (depression) also is characterized by symptoms of somatic dysregulation th at compromise health during pregnancy The patient actively participates and provides her evaluation of the acceptability of the various treatments and outcomes. Her capacity to participate in this process provides evidence of competence to consent. Included in the decision-making process are the pat ient's significant others and obstetrical physician. The process is ongoing , with the need for incorporation of additional data as the pregnancy and t reatment response progress. Conclusions: The conceptual model provides structure to a process that is f requently stressful for both patients and psychiatrists. By applying the mo del, clinicians will ensure that critical aspects of the risk-benefit discu ssion are included in their care of pregnant women.