I try to follow the New York Times’ Motherlode parenting blog as often as possible, because I always appreciate its intelligent and thorough coverage of parenting topics. That’s why I was a little surprised by yesterday’s story and its potentially misleading headline: Study Links Autism With Antidepressant Use During Pregnancy

The story, written by KJ Dell’Antonia, was about newly published research, a study entitled “Parental depression, maternal antidepressant use during pregnancy, and risk of autism spectrum disorders,” which appeared last week in the BMJ.

The study’s authors took a look at antidepressants taken during pregnancy, autism spectrum illnesses and maternal depression, trying to figure out what the associations were, if any, between these things. They found a small association between antidepressants taken prenatally and high-functioning autism like asperger’s, but were very careful not to make a direct link between autism and the use of antidepressants during pregnancy. Here’s some of what their published paper concludes:

“If antidepressants increase the risk of autism spectrum disorder, it would be reasonable to warn women about this possibility. However, if the association actually reflects the risk of autism spectrum disorder related to the non-genetic effects of severe depression during pregnancy, treatment may reduce the risk.”

And:

“From a public health perspective, if antidepressant use had a causal relation with autism spectrum disorders, it would explain less than 1% of cases, and therefore would be unlikely to explain the dramatic increase in the observed prevalence of these disorders.”

The headline infers that it may be antidepressants taken by mothers that are causing autism. To be fair, columnist KJ Dell’Antonia proceeds carefully in her story, explaining that there’s no way to know if the mothers’ severe depression caused the increased risk or the SSRIs did. Up until the middle of her piece everything was just fine.

But then the remainder of the piece was dedicated to an interview with Dr. Adam Urato, an OB/GYN who has been a vociferous opponent of antidepressants for years and has made several claims in the past about their use that I believe are misleading.

It comes as no surprise to me that Dr. Urato believes it’s no surprise that antidepressants are harming babies. His feelings about antidepressants are well known. At a site called RxRisk, he wrote, “The complications of SSRI use might be considered tolerable if there was solid evidence of benefit with the use of antidepressants by pregnant women. Sadly, in 25 years of study, not a single study has ever shown improvements in pregnancy outcomes in the antidepressant-treated group.”  HUH? You mean like this lack of evidence?  On the Citizens Commission for Human Rights website, he explains that research he conducted with Alice Domar found that “… there is no evidence of improved pregnancy outcomes with antidepressant use.” WHAT??!

When Domar and Urato’s paper came out last year, I reached out to Dr. Laura Miller for reaction. Dr. Miller is a reproductive psychiatrist, a researcher, and the director of Women’s Mental Health at Brigham and Women’s Hospital in Boston. Dr. Miller was so frustrated by the wide media dissemination of the Domar/Urato study that she wrote an incredibly detailed response. To the assertion that there’s no evidence of improvement of pregnancy outcomes with antidepressant use, for instance, she responded:

‘The authors state that, ‘There is an assumption in the psychiatric community that the risks to a fetus are greater if the mother has untreated symptoms of depression’.  This is not an assumption; it is a finding from numerous studies.  For example, untreated maternal depression during pregnancy is associated with reduced prenatal care (Marcus 2009), preterm birth (Li et al. 2009; Bansil et al. 2010), reduced birth weight (Henrichs et al. 2010), altered behavior at birth (Zuckerman et al. 1990), increased risk of infection (Rahman et al. 2004; Traviss et al. 2012), and more difficult temperaments (Huot et al. 2004).  There is increasing evidence that some of these effects are due to epigenetic influences on fetal development that are mediated by elevated cortisol levels (Glover et al. 2009; Oberlander et al. 2008).”

I highly suggest you read Dr. Miller’s entire response to their paper here.

I have to ask why there was no interview of a reproductive psychiatry expert in the Motherlode piece. Why no response from someone, anyone, who understands the impact of serious mental illness on mothers and children? It’s important to point out the risks of taking antidepressants during pregnancy, but why the focus on Urato, who has made some assertions about treatment of depression during pregnancy that, in my opinion, leave out the whole story (as Miller’s response suggests)? This issue is so charged, so painful to pregnant and prospective new moms who are trying to figure out the best thing to do for themselves and their babies, that it’s imperative to me that all sides of it be covered.

It’s clear to me that Dr. Urato has a bias against antidepressants. Then again, maybe I’m biased. Check that, I know I’m biased. I’m a full-time advocate for pregnant and new moms with perinatal mood and anxiety disorders.  I care immensely about the future health of babies, but equally as immensely about the mental health of mothers. This is why we HAVE to tell the whole story.

I was grateful to see that some of the public comments to the Motherlode piece reflected my feelings about the story. There was New York Times commenter Louise Kinross, who wrote:

“I’d like to hear from psychiatrists on the risk of not treating women with severe depression.”

I would have too, Louise.

And then there was commenter Nan Silver:

“Because it links extremely popular medications with a childhood diagnosis that parents deeply fear, this study is ripe for plenty of hype by irresponsible news outlets. I worry that it will now become gospel that antidepressants are responsible for the dramatic rise in autism rates. The study itself does not at all support that conclusion.”

I have the same worries, Nan.

And then Steve (oh, thank you Steve!):

“You quote only one physician commenting on the results, a Dr. Urato. Apart from his being an ob/gyn there is nothing to indicate that he has any special expertise in the area of treating of depression during pregnancy or about autism.”

He doesn’t.

I’m disappointed that the Times wouldn’t have included or at least hinted at the impact of untreated severe antenatal depression on infants and children in this story. Or the impact of severe untreated depression on pregnant mothers themselves. I’m disappointed that no actual expert on SSRIs in pregnancy, like Adrienne Einarson at Motherisk for one, was interviewed.

This morning I reached out to a few true experts on the topic of maternal mental health. One was Marlene Freeman, MD, Director of Clinical Services in the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital and an Associate Professor of Psychiatry at Harvard Medical School. After reading the Motherlode story she replied, “This is such a confusing and important topic, because there is so much we do not understand about autism, and of course it is such a serious condition.  The authors are very careful in stating that it is not possible to disentangle depression severity and antidepressant exposure, as both potentially being associated with an increased risk.”

“The authors of this BMJ paper do thoughtfully discuss limitations, and they do state that use of an antidepressant may represent women with most severe depression,” Freeman added. “In our clinical experience I would say that is true, that women with mild depression can successfully come off antidepressants, but those with more severe depression would be those for whom antidepressants are indicated.”

I also spoke with Samantha Meltzer-Brody, MD, Associate Professor and Director of the Perinatal Psychiatry Program, UNC Center for Women’s Mood Disorders, and she concurred with Dr. Freeman. “I believe this new paper must be taken with a grain of salt just like all of the other papers on this topic. Thankfully, the Swedish authors do carefully discuss potential limitations although the Motherlode article is more inflammatory,” said Meltzer-Brody. “One point that I don’t think can be emphasized enough— the overwhelming VAST majority of children with autism did not have mothers who took antidepressants during pregnancy! Women with moderate to severe depression during pregnancy need to be treated for their mental illness in the same way we treat all other medical conditions. There are always risks and benefits to consider. I am deeply saddened by the stigma and fear mongering that pregnant women with depression face when weighing treatment options.”

It is true there are risks to taking medication in pregnancy, including antidepressants. But let’s make sure moms know there are risks to suffering from severe depression and anxiety during pregnancy, too. If we’re going to report on this stuff, let’s report on all of it.

I have been and will remain a fan of KJ Dell’Antonia. I just had to write about this, because I believe the Times has a unique ability to reach and inform many, which gives it a particular responsibility in my mind. I need more from the New York Times when it comes to the lives of the hundreds of thousands of women each year who face the dilemma of whether to take antidepressants for their depression and anxiety during pregnancy.

Update 4/22 - I just read a blog post from Louise Kinross, one of the commenters I quoted above, who also wrote about the study. It’s worth a read: Making Sense of Autism Risks

Update #2 4/22 - KJ just updated her story this afternoon with links to both my post and Louise Kinross’, which I appreciate greatly.

Update #3 4/23 – I have updated the above story to correct a quote from Dr. Urato in paragraph 8. I also added in some links to data on the impact untreated depression in pregnancy has on children towards the end of the piece.