I wanted to share this letter with you, created by Dr. Laura Miller, a reproductive psychiatrist and the director of Women’s Mental Health at Brigham and Women’s Hospital in Boston. Here’s the information she offered to her own patients and other clinicians regarding the treatment of depression in pregnancy and the recent articles about it:

A recent review article (Domar et al. 2012) about the risks of selective serotonin reuptake inhibitor (SSRI) antidepressants during pregnancy and infertility treatment has generated considerable media attention.  In essence, it concludes that there is no credible evidence for the efficacy of SSRIs in treating mild to moderate depression in pregnancy and that exposure to SSRIs during pregnancy causes significant harm to fetus and newborn.  This has caused consternation and confusion among many patients and health care providers.  For this reason, leaders in the BWH Department of Psychiatry would like to clarify the evidence related to the article’s key points, as a guide for clinicians whose patients have questions.

Decisions about treatment with antidepressants during pregnancy are made on an individual basis. The authors assert at the outset that it is a “standard recommendation” that “the benefit of antidepressant use outweighs the risk of depression during the gestational and post-partum period”.  This is not the case.  The standard recommendation, repeated in the conclusions of numerous studies of antidepressant use during pregnancy, is to carefully weigh the risks of prescribing medication against the risks of withholding medication in each individual case.  This is well expressed in the words of a Food and Drug Administration (FDA) advisory regarding antidepressant use during pregnancy: “Women who are pregnant or thinking about becoming pregnant should not stop any antidepressant without first consulting their physician…The decision to continue medication or not should be made only after there has been careful consideration of the potential benefits and risks of the medication for each individual pregnant patient.”

Untreated depression in pregnancy is associated with adverse outcomes.  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).

Antidepressants, when appropriately indicated, are effective in the treatment of depression. The authors state that “The best available evidence suggests that antidepressants do not provide clinically meaningful benefit for most women with depression.”  While they raise the important point that publication bias has marred appraisal of the efficacy of many medications, including antidepressants, recent research using methodology to correct for publication bias (Duval and Tweedie 2000) continues to substantiate the efficacy of antidepressants.

Both depression and SSRI may have direct and indirect, positive and negative effects on fertility. Regarding the impact of antidepressants on fertility, the authors correctly state that systematic data are sparse.  A meta-analysis of 14 studies of women using assisted reproductive technologies found that depressive symptoms had no significant effect on the likelihood of becoming pregnant (Bolvin et al. 2011), although depression can contribute to a decision to stop infertility treatment earlier (Verhaak et al. 2010).  Retrospective data comparing women undergoing in vitro fertilization found no significant difference in pregnancy rates or live birth rates with or without SSRI use.  By contrast, some study findings suggest the possibility that SSRIs can reduce fertility in men (Safarinejad 2008; Tanrikut and Schlegel 2007; Tanrikut et al. 2010).

Obstetric and neonatal risks of SSRIs

The authors report a number of obstetric and neonatal risks of SSRI use during pregnancy as definitive findings.  Here are some clarifications: [Read more...]