An Expert Weighs In On Treatment for Depression In Pregnancy

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…]

The Harm of A One-Sided Story: Antidepressants and Pregnancy

antidepressants pregnancyNothing infuriates me like ignoring the facts. Presenting only one side of the story.

I hate it when people do that about maternal mental illness.  This week, there was a study that came out on the use of antidepressants during pregnancy. The study authors presented a very specific set of facts and ignored others. Here is the conclusion of the study, published in the journal Human Reproduction, that they used in their abstract:

Antidepressant use during pregnancy is associated with increased risks of miscarriage, birth defects, preterm birth, newborn behavioral syndrome, persistent pulmonary hypertension of the newborn and possible longer term neurobehavioral effects. There is no evidence of improved pregnancy outcomes with antidepressant use.

What does that say to you? It says don’t take antidepressants during pregnancy because they won’t help you and they’ll hurt your baby. This conveniently leaves out a lot of other important information.

When interviewed about the study, the authors then said, oh but we don’t want people to quit cold turkey. (Notice, they don’t say we don’t want people to quit antidepressants, just not cold turkey. Just go ahead and taper off and deal with it if you have a depression relapse.)  They also said, oh but women with severe depression during pregnancy may still need them. (I ask, what’s severe enough for them? When you’re right about to kill yourself?)

Sorry. You can tell me all you want that moms should make decisions on a case-by-case basis with their doctors, and then I’ll point you right back to your own abstract quoted above, which might as well say to mothers, do whatever is best for you but then deal with the consequences ladies because this stuff doesn’t work and it may cause you to lose your baby or have a baby with a birth defect. That’s what they want you to know.

If they had wanted you to look at all of the risks and benefits of taking or not taking antidepressants during pregnancy, to be aware of all the data available, to be able to make an informed decision, they would have looked at all the risks and benefits themselves. They didn’t.

Anyway, the whole thing makes me mad because I know how much this affects women. It’s not like it hasn’t happened before. The media always jumps on negative stories about antidepressants. Just read Lauren Hale’s blog post from 2009 on a story about antidepressants and pregnancy that appeared in Vogue magazine, for another example.

Walker Karaa, who writes for Lamaze’s Giving Birth With Confidence blog, did a story on the study this week. She interviewed the authors, and she interviewed experts on reproductive psychiatry. My favorite part of her piece is when she talks to Adrienne Einarson of Motherisk about all the things wrong with the science of the study.  There are more than a few.

I’ve chosen to take a look at what the study authors curiously left out over at my Something Fierce column on Babble. They left out studies finding that depression during pregnancy can negatively affect babies when it goes untreated. No one has said taking antidepressants during pregnancy is risk free. I certainly never have. But some of the risks people cite have not been proven out. And there are risks to not treating antenatal depression too. And yes, some women with depression during pregnancy will do just fine with cognitive therapy. I’ve said that. I’ve reported on acupuncture’s promising data. But let’s not confuse the issue of other treatment modalities effectively helping some women with using selective data that misleads.

I also wanted to take a look at how the media’s insistence on jumping all over any bad stories about antidepressants can hurt women. I think that’s SO important. I wish I could have included all of my readers’ input in my Babble story, because I received scores of comments. I encourage you to go read all of them on our Facebook page.

I hope you’ll read my piece at Babble. I published it there because I want the wider parenting community to understand what goes on in the reporting of maternal mental health by the media. I hope you read the other pieces I’ve linked to as well. And as more things get written about this, and I’m sure they will, I’ll add links to them here too.

Pregnancy Depression Was Like Running A Marathon With A Broken Leg

pregnancy depression, antenatal depression, prenatal depressionToday’s Warrior Mom is Lindsay H.  She was and still is very frustrated that there’s so little information out there about pregnancy depression, also called antenatal depression or prenatal depression.

It’s hard to pinpoint exactly when my world was turned upside down by pregnancy depression and anxiety. Somewhere between the not-so-pleasant thoughts of aborting my baby and the suffocating panic attacks I realized that this was not your average pregnancy. Something was definitely wrong, but wait, I was STILL PREGNANT. There was nothing postpartum about it. Everything I had read about depression or anxiety related to having babies talked about feelings after the birth, not during what was supposed to be a euphoric time of prenatal massages and glowing skin.

Pregnancy depression, also known as antenatal depression, is like trying to run a marathon with a broken leg. I felt like I had ruined my life by getting pregnant again and that I would never be the same. I just didn’t understand. I had always wanted a second child, but as soon as I saw that extra blue line, I panicked. Tears flowed like rivers and anxiety struck me like lightning. My hopes of feeling better dwindled every time I saw a new doctor who didn’t know what to do with me. I couldn’t find anyone who specialized in antenatal depression and was therefore lumped  in with everyone else, being prescribed antidepressants as if taking medication during pregnancy was supposed to help relieve my anxieties. Were they kidding?  [Read more…]

Weighing The Risks of Treating Antenatal Depression

There’s a new study out this week, published in the Archives of General Psychiatry, on the effect of taking antidepressants during pregnancy that essentially offers the same result as other studies we’ve reported on here:

Women with untreated depression during pregnancy have a higher risk of having pre-term babies.

Women who take antidepressants during pregnancy for depression have a higher risk of having pre-term babies.

Here was the conclusion of the study as outlined in the abstract:

Untreated maternal depression was associated with slower rates of fetal body and head growth. Pregnant mothers treated with SSRIs had fewer depressive symptoms and their fetuses had no delay in body growth but had delayed head growth and were at increased risk for preterm birth. Further research on the implications of these findings is needed.

It seems this is still a chicken and egg problem — is it something underlying the genetics of depression that leads to pre-term delivery or the medication or both? What should women do? [Read more…]