Pregnancy was once identified as a state of "bliss." Today we know that depression occurs in 8 to 11 percent of pregnant women. Even higher rates exist in the post-partum period. Depressed pregnant women were once advised by their physicians that "It is just your hormones" and that "It is just too risky to prescribe medication during pregnancy."
As a psychiatrist specializing in the treatment of women during pregnancy, I am regularly consulted by pregnant women, their families and their obstetricians about whether or not to use medication to treat a clinical depression during pregnancy. I heard recently about an outpatient psychiatric program that decided that psychiatrists would no longer be permitted to provide new prescriptions for antidepressants to pregnant women because the sponsoring institution had determined that the risk was too high. One-sided view of matters, I thought.
Depression itself is a risk to the mother's health. Clinical (or major) depression can be disruptive to mother-child bonding and the infant's development. Depression during pregnancy is associated with preeclampsia (pregnancy-induced high blood pressure and excess protein in urine), low birth weight, premature birth and developmental delay that appears by the time the child is a toddler. Depression during pregnancy is the best predictor we know of a woman developing postpartum depression. Pregnancy-associated suicide is not rare.
The decision to take medication during pregnancy is a difficult one. Let's start with your doctor: She or he must know both the risks of using medications and the risks of depressive illness to the mother and fetus. Currently, the medical literature reports outcomes for more than 20,000 women exposed to antidepressants during pregnancy. However, there are many limitations to this "birth defects" research. The "gold-standard" of ethical research requires a prospective controlled trial (where one group gets medication and the other gets placebo). This is not possible with pregnant women. Further, most of these studies rely on hospital or prescription records, birth registries or records of birth defects. Little is known in these studies about the actual dosage; the timing of exposure to the medication; whether the mother used other prescribed or over-the-counter drugs, alcohol or illegal substances; whether the mother smoked cigarettes; or even the medical or psychiatric condition of the mother. Any one of these factors could be a factor in increasing the risk of birth complications and fetal defects. However, if the pregnant woman received an antidepressant the birth defect is typically attributed to that medication.
Media publicity about antidepressants (in pregnant women and in general) has resulted in many pregnant women refusing medication. Some law firms have seized on this information and seek clients to bring lawsuits. Physicians and mental health professionals too are exposed to the same media and law firm advertisements and avoid the use of antidepressants, thinking that the risks of medication to the mother and fetus outweigh the possible benefits.
A careful examination of many birth defects studies, in fact, reveals contradictory results, but the emphasis is typically on the adverse outcomes to mother or infant. In 2006, a Public Health Advisory reported that the serotonin reuptake inhibitor (SSRI) antidepressants should be avoided in pregnancy because a study demonstrated an increased risk of persistent pulmonary hypertension of the newborn (PPHN) with SSRIs. PPHN is a failure of the normal circulatory changes at birth, which causes oxygen loss to the newborn. Many mothers refused the medication based on this information. In the past five years subsequent studies have not consistently replicated this earlier finding, and recently the FDA withdrew the recommendation, stating that physicians should not alter their clinical practice of treating depression during pregnancy.
A recent study that received widespread media attention suggested a higher rate of autism spectrum disorders in the children of 15 mothers treated with SSRIs. In addition to the small number of cases, the study did not account for the presence of psychiatric illness in the mother at the time of the study, although the association between psychiatric disorders and autism spectrum disorders is well known. Family history, genetic information, underlying medical illnesses and use of medications, alcohol or environmental exposures also were not considered in this report.
There is considerable evidence that the decision not to prescribe antidepressants to a woman who is depressed (or likely to have a recurrence of a depression) during pregnancy may generate greater risks to the woman and her fetus than the risks of exposure to the medication. Every pregnant woman is different, with different risks, protective factors and preferences. The doctor's job is to clearly communicate to everyone involved -- patients, their families and other physicians involved in the care of pregnant women -- what her or his view is of the risks and benefits.
How can you work with your physician to provide the best care for you? You need to take the position that your doctor is responsible for understanding and informing you of both the risks and benefits of available treatments. You are advocating for what is called "shared decision-making," and the task is even greater since you are responsible for yourself and your fetus and soon-to-be-born infant.
So often, after discussing what the medical literature tells us and meeting for 90 minutes with parents where I review the risks and benefits of treatment, I am asked "Doc, what would you do?" Did I not do my job and explain? Being partners in decision-making is a burdensome task for both doctor and patient. But it is your right as a patient and our responsibility as physicians.
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