Treating Depression in Pregnancy: Are Antidepressants Safe?

The most successful modalities for treatment of depression and anxiety in pregnancy are a combination of therapy (cognitive behavior therapy, EMDR-eye movement desensitization and reprocessing) and medication (most commonly the SSRIs-selective serotonin reuptake inhibitors like Prozac, Zoloft, Celexa, etc.).

As we discussed before, not treating poses some significant risks. Many patients respond to therapy only and this is certainly the safest modality. However, there are many women who do not respond to therapy alone.

Every few months, another study is published in the medical literature linking SSRIs used during pregnancy to birth defects. First, it's important to have an understanding of medical research. Many researchers agree that in order for a drug to be considered a teratogen (causing birth defects), this finding must be consistent across many studies. This has not been the case with SSRIs.

The one side effect that has been consistent is the risk of "neonatal adaptation syndrome" - a transient jitteriness that occurs for a few hours after birth. I certainly consider this a real risk that happens in 20-25% of pregnancies. However, the important word here is transient. All of the babies in these studies were eventually rooming in and went home from the hospital with their moms on day of discharge.

With the use of electronic medical records, we can now collect information from large administrative databases like Medicaid or health maintenance organizations about prescriptions written during pregnancy and a host of obstetrical and neonatal outcomes data.. Dr. Lee Cohen writes in the Sept 2011 issue of OB/GYN News "Conclusions about a teratogenic outcome or adverse perinatal outcome are only as reliable as the quality of the data from which the conclusions are derived, and, unfortunately, some of the data from these databases have been profoundly lacking".

Kaiser Permanente Northern California published a study using such data in the Archives of General Psychiatry in July 2011. They reported an association between an increased risk for autism spectrum disorders (ASDs) in children whose mothers used SSRIs during pregnancy. The study received considerable attention from the media and led to substantial concern from patients. Dr. Cohen pointed out many limitations of the study: (1) a very small number of SSRI exposures in the autism and control groups (2) it failed to take into account exposure to illness during pregnancy as a variable (3) The study failed to confirm actual ingestion of the drug by women who were prescribed an antidepressant (4) No measure of psychiatric disorder during pregnancy or the history and severity of psychiatric disorder in the past.

The use of medication to treat depression and anxiety during pregnancy needs to be made on a case-by-case basis. Pregnant women and their health care providers need to give careful thought to the treatment of depression and anxiety during pregnancy. It's important to take into consideration the risks of not treating and balance this decision with the longer-term prospective data regarding fetal exposure to SSRIs.