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Can You Take Antidepressants While Pregnant?
From the WebMD Archives
June 12, 2015 — If you're pregnant (or are trying to be) and you have depression, you might wonder if it's safe to take medicine to boost your mood. Will antidepressants harm your baby? Spend a day online and the ping-pong reports of their safety during pregnancy could make your head spin.
The issue has long been a topic of debate. Some studies suggest antidepressants are dangerous for babies in the womb. Others say the risks are extremely small, and that untreated depression poses a bigger threat to both the baby and mom.
Also, “there's an idea that antidepressants are a luxury medicine, and women should be pulling up their socks and getting through their pregnancy without taking them,” says Jennifer Payne, MD, director of the Women's Mood Disorders Center at Johns Hopkins. “But what most people do not understand is the risk of untreated depression to both the mother and baby is substantial.”
Depression affects millions of pregnant women. It's due in part to changes in the mood-boosting chemicals in the brain. Commonly used antidepressants can help balance these chemicals.
“Roughly about 1 in 10 women [takes] an antidepressant during pregnancy,” says Krista Huybrechts, PhD, an assistant professor of medicine at Brigham and Women's Hospital. She's written research on the topic, including a recent report.
Use of such meds by pregnant women has skyrocketed in the last two decades. One type, called selective serotonin reuptake inhibitors (SSRIs), now ranks among the top 20 drugs prescribed during pregnancy.
In 1998, no antidepressants made that list, according to a recent commentary in the Journal of Nervous and Mental Disease.
Despite the wide use, there is limited data on the drugs' dangers, because pregnant women are typically excluded from safety trials.
“It's an ethical dilemma,” says Siobhan Dolan, MD, an OB/GYN and medical advisor to the March of Dimes. “We understand why we exclude pregnant women from medication trials, but we don't have data to counsel them. So are we really helping them?”
Before you look at the potential dangers of antidepressants during pregnancy, it's important to understand how to interpret the information in research on the subject. Negative news always tends to spread more swiftly, particularly on social media.
Instead, ask this question: Did the researchers consider other health conditions — such as smoking or obesity — that could also affect study results?
Also, “women who take antidepressants are different than women who don't. They have other risk factors that can lead to problems during pregnancy. So is it the mental illness or the actual medication that causes the risks?” Dolan says.
Among the most publicized risks of taking an antidepressant during pregnancy is persistent pulmonary hypertension of the newborn (PPHN). It's a life-threatening condition in which a baby has high blood pressure in the lungs, causing severe breathing problems.
Scientists first linked it to the use of SSRIs in 2006, prompting the FDA to issue a warning about it.
Five years and five conflicting studies later, the FDA revised its statement, saying “it is premature to reach any conclusion about a possible link between SSRI use in pregnancy and PPHN.
” Since then, a handful of reviews, including one in June, have further reassured pregnant women that the risk is “statistically insignificant.”
“Our study by no means says that antidepressant use is safe during pregnancy. It is just that, for this outcome, we do not find an increased risk of PPHN,” says Huybrechts, who co-authored the study.
Another concern for moms-to-be taking these meds is the chance of heart defects in the baby. The FDA warned in 2005 that paroxetine (Paxil) could lead to holes and other structure problems in a newborn's heart. But a study published last year didn't confirm the risk.
About 3 in 10 babies born to moms who have taken SSRI have a temporary condition called poor neonatal adaption syndrome. Symptoms include:
- Low blood sugar
- Poor muscle tone
- Weak cry
Still, in at least one study, researchers say they don’t believe it causes long-lasting effects in a child.
Lots of research shows that depression during pregnancy can be bad for the health of mom and baby. If you have a mental illness and become pregnant, it's considered a high-risk pregnancy.
Pregnant moms who are depressed are:
- Less ly to get proper prenatal care
- Less ly to eat healthfully
- More ly to smoke and drink alcohol
Depression during pregnancy also raises your chances of conditions that can lead to infant death and illness, including:
- High blood pressure and organ damage during pregnancy (preeclampsia)
- High blood sugar during pregnancy (gestational diabetes)
- Baby being born too soon (preterm birth)
- Baby weighing less than 5 pounds, 8 ounces at birth (low birth weight)
There is no clear-cut answer. Using any medicine while you're expecting can be risky. “We tend to use older antidepressants, Prozac or Zoloft, because they've been around for a long time and if there's going to be an issue we would have seen it,” Payne says.
If you're pregnant and depressed, make extra time to weigh the risks and benefits of medication with your doctor.
“It's not a black and white issue. There's a lot to consider,” Dolan says. “Risk and benefits. Timing in pregnancy. Optimal medical management. Maybe you're on two or three antidepressants. Can you get down to one? A woman and her doctor need to personalize treatment. There's not a one-size-fits all answer. “
If you've been taking medicine for depression and become pregnant, don't stop taking it until you get your doctor's OK.
About 90% of women who quit their meds often see their depression come back during the last 3 months of pregnancy.
If a particular medicine has worked for you, experts in this article encourage you to stick with it and get regular tests to check the baby's growth and heart rate.
“The best antidepressant to use during pregnancy is the one that keeps the moms well,” Payne says.
Osborne, L. Journal of Nervous and Mental Disease, 2015.
Casper, R. Journal of Nervous and Mental Disease, 2015.
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March of Dimes website: “Depression in Pregnancy.”
Women's health.gov website: “Depression during and after pregnancy.”
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Krista Huybrechts, PhD, Assistant Professor of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston.
Siobhan Dolan, MD, obstetrician gynecologist (OB/GYN), clinical geneticist, and medical advisor to the March of Dimes.
Jennifer Payne, MD, director, Women's Mood Disorders Center, Associate Professor of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, Baltimore, MD.
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© 2015 WebMD, LLC. All rights reserved.
Antidepressants in Pregnancy: Balancing Needs and Risks in Clinical Practice
A practical approach to antidepressant use in pregnancy
How do we integrate all the information about the risks of both treatment and lack of treatment into a practical clinical approach? The ideal situation is to begin planning for pregnancy before conception.
The patient’s psychiatric history, severity of illness, past medication response, and wishes for treatment during pregnancy should be taken into account. Every case should be considered individually.
Ultimately, there is no set approach: just the weighing of risks and benefits of the various options for the individual patient.
The primary goal of treatment in pregnancy is to minimize the number of exposures. This means not only minimizing the number of medications but also limiting exposure to psychiatric illness.
When determining which antidepressant to use during pregnancy, remember that in general we have more information about older antidepressants than newer ones. This fact is reflected in the old FDA pregnancy categories.
Categories include A, B, C, D, and X, and the hierarchy is the amount of evidence for safety in animal and human studies, not on the level of risk.
Medications in category B simply have not been studied adequately in humans to warrant placing them in category A as safe (or in C, D, or X), and most medications new to the market will therefore be in category B.
Prescribers may make the mistake of prescribing a category B medication over an older medication in category C or D, thinking it is safer, when in fact less is known about its safety during pregnancy. While these categories are being phased out, they will still apply to drugs approved before 2001 for some time.
Should women switch to better-studied medications before pregnancy? If decisions are being made well in advance, and the woman does not have a history of non-response to the better-studied medication, she can attempt a switch.
Switching to another antidepressant during pregnancy rarely makes sense (unless the woman is not responding), since the baby has already been exposed and switching would increase the number of exposures to medications and potentially depressive illness.
What if the patient is already pregnant? The same principles apply, with an important addition: don’t stop all psychiatric medications immediately. Stopping precipitously can cause great distress, precipitate withdrawal, and induce a relapse of mental illness.
The best approach is to review the medication list the principles outlined above.
Keep in mind that the baby has already been exposed, and while stopping some medications may make sense to minimize the impact on the child, doing so in a controlled and logical fashion is ideal.
Despite increasing evidence of safety, many patients decide not to take psychiatric medications during pregnancy. Many feel guilty about taking any medication during pregnancy, and most women overestimate the risks of medication and underestimate the risks of untreated mood disorders during pregnancy.
In this situation, it is appropriate to offer close follow-up care so that relapses are identified early and treatment can be offered.
Evidence-based nonpharmacological treatments, including psychotherapy, yoga, and acupuncture, should be incorporated whenever possible (whether the patient is receiving medication or not!).
It is also important to keep in mind that the patient and her family must feel comfortable with the treatment used during pregnancy, so they do not look back and regret decisions made during this critical period.
Educating the family about the risks and benefits of treatment, the risks of untreated psychiatric illness to both mother and child, as well as signs and symptoms of relapse, is essential to providing good clinical care.
Interpretation of the literature on in utero antidepressant exposure is complicated by confounding variables associated with psychiatric illness. Current evidence is generally reassuring and indicates that the absolute risks of negative infant outcomes are small except for PNAS, which largely appears to be self-limited.
In contrast, the risks associated with exposure to significant maternal depression are substantial. A plan to minimize the number of exposures both to medication and to illness, along with close psychiatric follow-up and communication with all involved parties, serves to maximize outcomes for both mothers and their children.
Dr. Osborne is Assistant Director, Women’s Mood Disorders Center, Johns Hopkins School of Medicine, Baltimore, MD, and Assistant Professor of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine. Dr.
McEvoy is a Postdoctoral Fellow in Women’s Mental Health in the Department of Psychiatry, Johns Hopkins School of Medicine. Dr.
Payne is Director, Women’s Mood Disorders Center, Johns Hopkins School of Medicine, and Associate Professor of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine.
Dr. Osborne reports no conflicts of interest concerning the subject matter of this article. Dr. Payne receives research support from and is a consultant for Sage Therapeutics; she has provided expert testimony for Eli Lilly, Astra Zeneca, Johnson and Johnson, and Abbott Pharmaceuticals.
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