By Orit Avni-Barron, MD
Pregnancy is not child’s play. Morning sickness, varicose veins and not-fitting-into-your-jeans aside, the constant awareness of everything that can go wrong during pregnancy is often overwhelming. Throw depression or anxiety into the mix, and things can quickly go south.
About one in ten women are prescribed an antidepressant during pregnancy – most often for depression or anxiety but also for other indications like eating disorders. Stigma, fear and lack of knowledge may lead women to stop treatment prematurely (often upon discovery of an unplanned pregnancy). Discontinuing medication, especially when it is done abruptly, can expose women to a host of other problems.
The current information available to women about using antidepressants during pregnancy can be quite confusing. New studies are abundant but difficult to interpret. Media coverage often focuses on horror stories about women suffering with extreme — often untreated — depression and anxiety (think Andrea Yates).
At the same time, TV commercials solicit law suits against prescribers who attempt to treat and prevent such cases. Navigating this mine field is often challenging and even health care providers struggle with making recommendations to their patients. For women, this can result in getting different messages from different providers about the risks and benefits of taking medications while pregnant.
The final decision about treatment ultimately falls on the patient’s shoulders. She is the one who needs to put that pill in her mouth and swallow it. And then she needs to do it again, and again and again. Every day.
This woman may already be compromised by anxiety or depressive symptoms. Or, she may be symptom-free thanks to an antidepressant and scared of the way she might feel off it. Like most women, she probably feels guilty about taking medication during pregnancy. She may be embarrassed about needing treatment, maybe even hide this fact from loved ones. Her partner has an opinion about what she needs to do. Her friends tell her about an esoteric fact they heard about the particular antidepressant she’s taking. She wants to do right by her baby…she can’t tolerate the despair and anxiety.
As a women’s mental health specialist I’ve often witnessed women struggle to find a definitive answer. Some focus on getting information from multiple resources (the Web, second and even third opinions, etc.) and end up feeling more confused and frustrated. Others want to be told what to do, relieving themselves of the burden of responsibility for any negative outcome. I find it interesting that women thank their good luck when their baby is born healthy, but blame themselves when she is not. When I counsel women about treatment with antidepressants during pregnancy, I give them the facts and the tools to understand them in order to make a decision.
Of course, it’s best to try to plan — before conception — how best to deal with mental health issues that might arise during pregnancy. This, however, is often impossible: about half of pregnancies in U.S. are unplanned.
What do women need to know about taking antidepressants during pregnancy?
Here are the facts:
• Anxiety and depressive disorders are real conditions that may cause tremendous distress and suffering. Treatment is, therefore, indicated whether or not patients are pregnant. Medication is not the only option, but it is often recommended for moderate to severe symptoms that interfere with an individual’s ability to function.
Untreated depression and anxiety disorders are not risk free during pregnancy and may negatively affect the mother, her baby or both. These disorders may:
1. Affect the mother’s feelings and behavior by increasig anxiety about OB visits or diminish energy levels to the point that prenatal care suffers. Poor appetite or fear of gaining weight may lead to poor nutrition. Depression or intense preoccupation may affect the mother’s ability to bond with her baby.
2. Lead to overuse of harmful substances (like alcohol, nicotine, excessive coffee intake, to name a few) to manage distressing symptoms.
3. Increase the risk of problems like nausea and vomiting, pre-term labor, low birth weight, lower Apgar scores (a measure of the baby’s health immediately after birth), enduring emotional and cognitive changes in the baby and post-partum depression.
• Treatment with antidepressants during pregnancy has also been associated with potential risks. Some are simply side effects of the medications which could be problematic during pregnancy (e.g. excessive weight gain or loss), some (like pre-term labor) are similar to the risks of no treatment. Yet others include an increased risk of miscarriage.
As a group, malformations have not been associated with antidepressant use during pregnancy. Up to 30% of babies exposed to antidepressants in utero suffer from mild, transient symptoms like excessive crying, respiratory distress and irritability that typically resolve within 1-4 days. More severe outcomes (like Primary Pulmonary Hypertension of the Newborn, or PPHN, a rare condition in which babies do not get enough oxygen and may require mechanical ventilation) and autism have been implicated, with an increased risk that is either not well supported or not clinically significant.
• Abrupt discontinuation of antidepressant treatment during pregnancy may lead to relapse of the underlying problem and in some cases, even suicidal thoughts.
• Herbs, food supplements and other over-the-counter agents are not necessarily safe or safer than antidepressants. Omega 3 essential fatty acids are the only supplement that has been found to safely reduce depressive symptoms during pregnancy.
This is a lot to digest.
But it is important to remember overall that when it comes to anxiety or depression during pregnancy, no decision is risk free, and that the potential benefits of treatment need to be balanced not only against the potential risks but also against the potential risk of no treatment. (Ideally, these decisions are best made by both parents of the baby, when possible.)
No two women are alike. Each has an individual history, a set of genetic and psychosocial traits and vulnerabilities and her own, specific circumstances. The decision about treatment with antidepressants during pregnancy should, therefore, be made on an individual basis with a knowledgeable provider who knows how to interpret available data and help the couple reach the right decision for them.
Orit Avni-Barron, MD, is a psychiatrist and the founding director of the womens mental health service at The Fish Center for Womens Health of the Brigham and Womens Hospital, Boston. She is also an Instructor of Psychiatry at Harvard Medical School.