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Wednesday, January 16, 2013

Anti-depressants in Pregnancy: What are the Risks?

Women with major depressive disorder often become pregnant and women who are pregnant often develop major depressive disorder (referred to as depression going forwards). While the safest form of treatment for depression is counseling (usually with a psychologist) another common form of treatment is anti-depressant medication.

Anti-depressant medications, like all medications, have side effects and there is controversy about whether these medications should be used during pregnancy.

Researchers recently published a critical review of the scientific literature on anti-depressant medication use in pregnancy in the journal, Acta Psychiatrica Scandinavica. The authors found that no single type of birth defect has been consistently observed across research studies with any anti-depressant medication that is commonly used.  Some studies suggested associations between some specific birth defects and anti-depressant use in pregnancy but the findings were not consistent. 

These specific medications in which such inconsistent association were noted was in a class known as selective serotonin-reuptake inhibitors (SSRIs). SSRIS work to block the re-uptake of a chemical messenger in the brain known as serotonin. This makes more serotonin available, which improves mood. SSRIs are among the most commonly prescribed anti-depressant medications and are the most studied anti-depressant medications in pregnancy. Since all SSRIs cross the placenta, they can transport increased levels of serotonin to the fetus. The placenta is an organ in the uterus (a hollow organ in which a baby develops) that links the blood supply of the mother to the developing fetus and by which the fetus can release wastes.

Another finding was that postnatal adaptation syndrome (PNAS) occurs in up to 30% of neonates exposed to antidepressants in late pregnancy. PNAS is a cluster of signs and symptoms in infants that includes irritability, lack of energy, decreased activity, decreased feeding,  abnormal rapid breathing, abnormal crying, tremor, and difficulty breathing. PNAS usually lasts for days to weeks (up to 6 weeks) after delivery.  Some studies suggested a small association between persistent pulmonary hypertension of the newborn (PPHN) but others did not (the evidence is inconclusive). Pulmonary hypertension is when more blood than necessary is pumped to the lungs.

The authors cautioned that when evaluating research studies on this topic it is important to consider whether researchers took into account diagnoses of the mother or other factors that can confound the study outcome, whether they used adequate control groups (e.g., infants exposed to no medications or another class of medications), whether the infants were systematically  assessed, and whether those rating the infants knew if they were exposed to anti-depressant medications.

The authors suggested that doctors should have individually-tailored discussions with each pregnant woman about these issues who are considering anti-depressant use during pregnancy. They noted that past medication trials, previous success with symptom remission, and women’s preferences should guide treatment decisions.

Suggested Reading: Taking Antidepressants: Your Comprehensive Guide to Starting, Staying On, and Safely Quitting

Related Blog Entry: Preventing Post-partum Depression in Adolescent Mothers

Reference: Byatt N, Deligiannidis KM, Freeman MP. (2013). Acta Psychiatr Scand. 127(2):94-114. Antidepressant use in pregnancy: a critical review focused on risks and controversies.

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