Peculiarities of prescribing antidepressants during pregnancy
Psychopharmacotherapy during gestation is subject to strict rules. As a general rule, psychotropic drugs are not prescribed to pregnant women due to the risk of toxic effects on the fetus and subsequent accumulation of substances in breast milk. Special caution must be exercised during the first trimester of pregnancy.
However, there are situations where treatment is unavoidable. One such absolute indication is depression with a high suicidal risk (along with acute psychosis and severe epilepsy). In these cases, the physician is guided by the following principles:
- The least hazardous drugs for the fetus that are simultaneously the most potent are selected.
- Therapy is administered at the minimum effective dosages.
- Drugs of choice: among antidepressants, preference is given to tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). Important exception: the use of paroxetine is strictly prohibited.
Patient management in the perinatal period requires timely dose adjustments. Two weeks before the expected date of delivery, antidepressants and other psychotropic agents are gradually tapered off to prevent withdrawal syndrome in the newborn infant. Immediately after delivery, the patient is returned to her previous therapeutic dose of the medication to prevent the development of postpartum psychotic and severe depressive states. Meanwhile, the administration of corrective drugs (such as diphenhydramine or trihexyphenidyl) is highly undesirable.
Interaction between antidepressants and antipsychotics
Antipsychotic agents (antipsychotics) are not able to independently relieve fully developed clinical depression. Moreover, classical conventional antipsychotics, such as the aliphatic phenothiazine derivative chlorpromazine (aminazine) and the alkaloid reserpine, can themselves provoke the development of severe pharmacogenic depression with prolonged use.
Nevertheless, antipsychotics play a crucial role in the management of depressive states during the initial stages of treatment. The main problem with antidepressants is their delayed therapeutic response—their clinical effect develops gradually. In the acute phase of the disease, when the patient suffers from pronounced anxiety or has serious suicidal intent, immediate intervention is required.
Advantages of antipsychotics in the acute phase:
- Rapid onset of effect (drugs with a sedative component act within 10–20 minutes after administration).
- The ability to rapidly induce a state of calm and emotional indifference in the patient.
- Reliable prevention of suicide attempts.
Thus, antipsychotics are used as a "bridge," allowing the clinician to safely wait for the point where the main antidepressant therapy begins to work at full capacity.
Antipsychotics with intrinsic antidepressant activity
Although classical antipsychotics target the blockade of dopamine (D₂) receptors to relieve psychosis (delusions, hallucinations, agitation), certain chemical classes of antipsychotics possess a specific spectrum of action that includes a mild antidepressant effect. This allows them to be used in monotherapy for psychosomatic disorders or as part of complex treatment for anxious and agitated depression.
Drugs possessing a mild antidepressant effect include:
- Benzamide derivatives: drugs in this group (e.g., sulpiride) are characterized by a mild action. They are well tolerated, produce few side effects, and successfully combine a calming influence with an antidepressant effect. They are often used in psychosomatic diseases accompanied by depressed mood.
- Selected representatives of other classes: pronounced effects on anxious depressions are exerted by such drugs as levomepromazine, the atypical antipsychotic quetiapine, the thioxanthene derivative chlorprothixene, and the piperidine phenothiazine derivative thioridazine.
Such drugs do not replace a full course of antidepressants for severe clinical episodes, but they effectively complement the treatment regimen by acting simultaneously on a wide range of presynaptic receptors (including serotonin 5-HT and noradrenergic α₁ receptors), which clinically manifests as improved mood, normalization of behavior, and reduced aggressiveness and conflict in patients with neurotic manifestations.
Briefly: answers to topical questions
What classes of antidepressants are used in clinical practice besides TCAs and SSRIs?
In addition to tricyclic antidepressants and selective serotonin reuptake inhibitors, the following classes are used in clinical practice:
- MAO inhibitors — classical non-selective (nialamide) and selective reversible agents (pirlindole, moclobemide).
- Dual-action agents — affect both the serotonergic and noradrenergic systems (mianserin, venlafaxine, duloxetine).
- Tetracyclic antidepressants — mirtazapine belongs to this group.
- Melatonin receptor agonists — normalize circadian rhythms and ensure stable sleep (agomelatine).
What are the main side effects characteristic of tricyclic antidepressants?
The main side effects of tricyclic antidepressants are due to their pronounced anticholinergic and sedative actions.
- Frequent effects — dry mouth, accommodation disorders, constipation.
- Dangerous complications — cardiac rhythm disturbances (up to sudden cardiac arrest) and dysuria (up to acute urinary retention).
- Other disturbances — weight gain, blood pressure fluctuations, pupil dilation with the risk of an acute glaucoma attack.
They are also characterized by high toxicity in overdose.
What are the indications for prescribing antipsychotics with antidepressant activity?
Antipsychotics with antidepressant activity are prescribed for depressive states and psychoses as symptomatic therapy.
- Acute phase of depression — to reduce anxiety and prevent suicide (they rapidly induce calmness, allowing time to wait for the antidepressants to take effect).
- Anxious and agitated depression — levomepromazine, quetiapine, sulpiride, thioridazine, and chlorprothixene are used.
- Schizophrenia with a depressive component — the prescription of dicarbine is indicated, which is a "mild" antipsychotic with antidepressant activity.
- Alcoholic psychoses — are also an indication for prescribing dicarbine.
Class and exam questions
Can antidepressants be prescribed to pregnant women?
In general, psychopharmacotherapy is not recommended for pregnant women, but for depression with suicide risk, TCAs or SSRIs are used. Paroxetine is strictly excluded in these cases.
Why are antipsychotics prescribed for depression?
They are needed in the acute phase for the rapid relief of anxiety and the prevention of suicide, since antidepressants do not work immediately.
Can antipsychotics cause depression themselves?
Yes, some conventional antipsychotics, especially chlorpromazine and reserpine, can provoke depressive states with prolonged use.
What else to study on this topic
- Mechanism of 5-HT and α₁ receptor blockade by psychotropic agents
- Management tactics for newborns experiencing psychotropic drug withdrawal syndrome
- Classification and pharmacokinetics of tricyclic antidepressants (TCAs)
- SSRIs: mechanism of action, indications, and safety profile
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