Should Pregnant Women Take Antidepressants?

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The risks associated with the use of antidepressants by pregnant women is the focus of a just-released joint report from the American College of Obstetricians and Gynecologists (ACOG) and the American Psychiatric Association (APA). Although the report provides some important guidelines for pregnant women about possible antidepressant use, it also leaves many questions unanswered about the dangers the drugs pose to the infants.

The dilemma has several facets. Accurate diagnosis of depression during pregnancy can be problematic because its symptoms are similar to those women experience during pregnancy, such as mood swings, low energy level, and changes in appetite. Research has shown that while depression is associated with premature births and changes in fetal growth, use of antidepressants may also cause medical problems for newborns. Thus, if a pregnancy woman is depressed, doctors may be hesitant to treat them because of the unknowns regarding drug treatment.

For example, research shows that in 2003, one in eight pregnant women took an antidepressant during her pregnancy. This rate of use reflects a two-fold increase in antidepressant use during pregnancy between 1999 and 2003. Drugs such as Prozac (fluoxetine), Zoloft (sertraline), and Paxil (paroxetine), which belong to the drug class of selective serotonin reuptake inhibitors (SSRIs), were associated with the increase.

Despite early reports that these SSRIs were safe for pregnant women, studies soon came out indicating that use of Paxil during pregnancy increased the risk for congenital heart defects in the delivered infants. A subsequent study, however, reported that the evidence was inconclusive. Other studies have suggested that use of SSRIs during pregnancy is associated with an increased risk of premature birth, miscarriage, and low birth weight.

In another example, a study published in the August 18, 2009 issue of Depression and Anxiety reported a significant increase in incidence rate in preterm births associated with the use of various antidepressants (including but not limited to bupropion, citalopram, paroxetine, venlafaxine, and sertraline) during pregnancy. In another article, which reported on a study of the same group of pregnant women, the researchers found no significant difference in the number of infants born with major malformation of women who had taken antidepressants during pregnancy and those who had not.

So, should pregnant women take antidepressants? The guidelines presented in the jointly prepared ACOG/APA report include a recommendation that women who plan to become pregnant should gradually reduce their use of antidepressants and stop them completely if they have had mild or no symptoms for at least six months. No woman, however, should stop taking her medication without her doctor’s supervision.

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Among some of the other recommendations from the ACOG/APA report are the following:

* Pregnant women who are psychiatrically stable who want to keep taking antidepressants should talk to their ob-gyn and psychiatrist about the potential risks and benefits

* Pregnant women should not attempt to stop their antidepressant use if they have severe depression

* Pregnant women who suffer recurrent depression or those who still have symptoms despite drug treatment may benefit from psychotherapy

* Women who are pregnant but not taking medication for depression may benefit from psychotherapy rather than antidepressant medication

* Any pregnant woman who has psychotic or suicidal symptoms should see a psychiatrist immediately for treatment

Additional recommendations can be read in the joint report, “Depression during Pregnancy: Treatment Recommendations.”

SOURCES:
American Psychiatric Association and American College of Obstetricians and Gynecologists joint report
DG News August 21, 2009
Einarson A et al. Depression and Anxiety 2009 Aug 18; Epub before print
Einarson A et al. Canadian Journal of Psychiatry 2009 Apr; 54(4): 242-46
WebMD August 21, 2009

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