Depression and Treatment of Depression in Pregnancy
Depression and Treatment of Depression in Pregnancy
During the last 20 years or so, there has been an enormous attention to the clinical issue of prescribing antidepressants during pregnancy. Because 7-10% of pregnant women use antidepressants during pregnancy, there are concerns about the effects of fetal exposure to selective serotonin reuptake inhibitors (SSRIs). The answer to this issue is not as simple as coming off antidepressants as soon as pregnancy is diagnosed. The risk for relapse of depression during pregnancy in women who have stopped antidepressants is very high.
There have been extraordinary large number of studies looking at risk for organ malformation with SSRI exposure and there is an absence of data to support these concerns. However, there are studies that have suggested the complication of persistent pulmonary hypertension of the newborn; however, the level of risk seems to be lower than the original studies suggested and there may be some of the SSRIs that have minimal or no risk. Some of the more commonly used SSRIs including Celexa (citalopram), Zoloft (sertraline), Lexapro (escitalopram) and Prozac (fluoxetine) seem to have very small risk. The original study that pointed the finger at the risk of heart defects and persistent pulmonary hypertension of newborn was with Paxil (paroxetine). For that reason and the fact that repeat studies have not been performed, Paxil should not be used during pregnancy.
Another risk that is noteworthy is an increased risk of hypertension in the mothers taking SSRIs during pregnancy. This is a larger risk in women who take serotonin and norepinephrine reuptake inhibitors (SNRIs) than with the pure SSRIs. Examples of these medications include Cymbalta (duloxetine), Effexor (venlafaxine) and Wellbutrin (bupropion).
The prevalence of transient neonatal symptoms such as jitteriness and tachypnea (rapid breathing) in the babies of women who have used antidepressants during pregnancy is commonly observed. This is sometimes called "poor neonatal adaptation syndrome." This may require observation of the baby in the special care nursery for a short period of time but seems to resolve within 2 weeks after birth.
What is not known is if there are long-term neurodevelopmental sequelae in these children. Although it has been looked for, there is sparse evidence linking these medications with autism or ADHD. There may be a relationship to developmental outcomes such as language ability, cognition, academic performance, language, math and other cognitive skills; however, the children of women with untreated maternal psychiatric illness also demonstrated an increase in these neurodevelopmental abnormalities.
Risks of Depression in Pregnancy
Women with depression during pregnancy are at increased risk for pregnancy related complications of PTB, LBW and IUGR, although the magnitude of the effect varies as a function country location and in the US, socioeconomic status. A meta-analysis study performed in 2010 showed that the relative risks (RRs) for preterm birth (PTB), low birth weight (LBW), and intrauterine growth restriction (IUGR). were significantly increased (pooled RR [95% confidence interval] = 1.39 [1.19-1.61], 1.49 [1.25-1.77], and 1.45 [1.05-2.02], respectively) in women with antenatal depression compared with controls.
The risk of LBW associated with antenatal depression was significantly higher in developing countries (RR = 2.05; 95% confidenceinterval, 1.43-2.93) compared with the United States and (RR = 1.10; 95% confidence interval, 1.01-1.21) countries in the European Union.
In the United States, women of lower socioeconomic status with antenatal depression tended to have an increased risk for PTB and IUGR compared to the more affluent controls.
These findings are not unexpected, and my first thought is that I am glad that we live in the United States, and I wish that we all had a comfortable socioeconomic status. Co-morbidities of race, nutrition, drug use and prenatal and general medical care are also associated with a low socioeconomic status and are also associated with pregnancy related problems.
Important Take Aways
- An important message is that antenatal depression should be identified and when recognized treated.
- Because some of the medications used to treat depression have been associated with a higher risk of health problems for babies and mothers, the options for treatment should be carefully evaluated.
- The risks can be mitigated by choosing medications that have NOT been associated with abnormalities, prescribing a single medication if possible and using the lowest effective dose.
- If your depression is under good control, there is little reason to think that changing to a new medication is necessary. This may result in a different medication that might not work and an increased risk of relapse in your depression.
