Comparative Effectiveness of Treating Prenatal Depression with Counseling versus Antidepressants in Relation to Preterm Delivery.

Background: Maternal depression during pregnancy is prevalent and has been associated with increased risk of preterm delivery (PTD). However, comparative effectiveness of two commonly used treatment options, mental health counseling and use of antidepressants, in mitigating the risk of PTD associated with maternal depression remains uncertain. Although antidepressant use has been associated with increased risk of PTD in many previous studies, a direct head-to-head comparison between these two treatment options has not been investigated. Thus, the comparative risk-benefit profiles of those two treatment options remain unclear.

Objectives: To determine the comparative effectiveness of two commonly used options for treating prenatal depression in limiting the risk of PTD associated with maternal depression.

Study design: A large prospective cohort study was conducted among 82,170 pregnant women at Kaiser Permanente Northern California (KPNC), an integrated health delivery system. Clinically diagnosed depression and its treatments (use of antidepressants and mental health counseling) were identified from the KPNC electronic health record system (EHR). Gestational age was also recorded for all deliveries and captured by EHRs for determining PTD.

Results: Using Cox proportional hazards regression incorporating propensity score methodology to ensure comparability between comparison cohorts, relative to those without depression, pregnant women with untreated depression had 41% increased risk of PTD: adjusted hazard ratio (aHR)=1.41, 95% confidence interval (CI)=1.24-1.60, confirming increased risk of PTD associated underlying maternal depression. Relative to untreated depression, any mental health counseling was associated with a 18% of reduced risk of PTD: aHR=0.82 (0.71-0.96). The inverse association showed a dose-response pattern: increased number of counseling visits was associated with greater reduction in PTD risk with 43% reduction in PTD risk associated with 4 or more visits (aHR=0.57, 95% CI=0.45-0.73). In contrast, use of antidepressants during pregnancy was associated with an additional 31% increased risk of PTD independent of underlying depression: aHR=1.31, 95% CI=1.06-1.61. This positive association also showed a dose-response relationship: a longer duration of use was associated with an even higher risk.

Conclusions: This study provides much needed evidence regarding the comparative effectiveness of two common treatment options for prenatal depression in the context of PTD risk. The results indicate that, to reduce PTD risk due to maternal depression, mental health counseling is more effective. Use of antidepressants may add additional risk of PTD, independent of the underlying depression. The findings provide data for clinicians and pregnant women to make informed and evidence-based treatment decisions that take into account the risks and benefits to both maternal and fetal health.