Treating Depression in Pregnant Women
Women who take antidepressants face a difficult choice when they become pregnant, and for many the risks vs. benefits of continuing treatment are not clear, a joint report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists finds.
The report confirms that there are far more questions than answers about the dangers antidepressants pose to the babies born to women who take them.
It also presents guidelines to help doctors and patients identify who should and should not consider stopping drug treatment.
Pregnant women who experience psychotic episodes, have bipolar disorder, or who are suicidal or have a history of suicide attempts should not be taken off antidepressants, the report concludes.
"We know that untreated depression poses real risks to babies. That is not conjecture," Yale University School of Medicine ob-gyn Charles Lockwood, MD, tells WebMD. "We know much less about the risks associated with antidepressant use. It is clear that more study is needed."
According to one study, the rate of antidepressant use during pregnancy more than doubled between 1999 and 2003. The study found that in 2003, one in eight women took an antidepressant at some point during her pregnancy.
Greater use of selective serotonin reuptake inhibitor (SSRI) antidepressants like Prozac, Paxil, and Zoloft were largely responsible for the increase.
These drugs were generally considered safe for pregnant women at the time, but safety concerns soon emerged, especially regarding Paxil.
Separate studies from Sweden and the U.S. suggested an increased risk for congenital heart defects in babies born to women who took Paxil during pregnancy.
The reports led the FDA to issue an advisory in December 2005 warning about the potential risk based on early results of two studies.
But the joint panel found the evidence linking Paxil use during pregnancy to heart problems in newborns to be inconclusive.
Lockwood tells WebMD that if the risk is real, it is probably not limited to Paxil alone.
"It is very likely to be a class effect and not just this one drug," he says.
Miscarriage, Low Birth Weight, and Preterm Birth
SSRI use during pregnancy has also been linked in some studies to an increased risk for miscarriage, low birth weight, and preterm delivery.
But once again, the report found no definitive link between the use of the antidepressants and these pregnancy outcomes.
"Antidepressant use in pregnancy is well studied, but available research has not yet adequately controlled for other factors that may influence birth outcomes including maternal illness or behaviors that can adversely affect pregnancy," the joint panel writes.
The report was published in both the American Psychiatric Association journal General Hospital Psychiatry and the American College of Obstetricians and Gynecology journal Obstetrics and Gynecology.
The joint panel concludes that a gradual reducing of antidepressant dosages and stopping antidepressants altogether may be appropriate for women who hope to become pregnant if they have had mild or no symptoms for six months or longer.
The group also recommended that:
- Women who are already pregnant should not attempt antidepressant withdrawal if they have severe depression.
- Psychiatrically stable women who want to stay on antidepressants during pregnancy should consult with their psychiatrist and ob-gyn about the potential risks and benefits.
- Women with recurrent depression or those who have symptoms despite drug treatment may benefit from psychotherapy when available.
Psychiatrist Ariela Frieder, MD, who specializes in treating pregnant women with depression at Montefiore Medical Center in New York City, tells WebMD that her patients tend to be very concerned about how antidepressants will affect their baby and much less aware of the dangers posed by untreated depression.
Frieder was a practicing ob-gyn in her native Argentina before moving to New York where she did her residency in psychiatry.
"Many women want to stop treatment abruptly and even stop on their own, but this can be very risky," she says.
Jennifer Wu, MD, an ob-gyn who practices at New York's Lenox Hill Hospital, agrees.
"The old conventional wisdom was that pregnancy was a honeymoon period for depression and that patients would be able to come off their medications and be OK," she tells WebMD. "But we have learned that this is not true. It has become more and more apparent that pregnancy is a vulnerable time for patients with a history of depression."
