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David Baxter PhD

Late Founder
Depression dilemma in pregnancy: Ditch meds?
By Rachel Rettner, MSNBC
April 17, 2011

Experts argue over whether it's worse to leave depression untreated ? or take potentially risky medication

In January 2008, Clori Rose, a high school teacher in Atlanta, was halfway through her pregnancy when she started to notice a significant change in her emotions. A remark from a student that she normally would have brushed aside sent her into a state of distress.
"It made me cry, and I seriously couldn?t stop crying for 24 hours," Rose said. "I was so upset I had to call in sick."

Having battled depression on and off for years, Rose went to see her psychiatrist who diagnosed her as having stress and anxiety disorder brought on by pregnancy. He advised her to take Wellbutrin, an antidepressant, to cope with her mood changes. Her obstetrician prescribed Zoloft, another type of depression medication. Both told her the drugs posed only a small risk to the fetus, but Rose remained unconvinced.

After doing her own research, and discussing it with her psychiatrist, Rose decided not to take the drugs ? unsure of what they would do to her unborn baby girl.

"I just didn?t find in my research that anyone could conclusively say to me that it wouldn't hurt her," Rose said.

"I guess my biggest thing was, what if down the line we found out she had ADHD, or a learning disability, or something, and in the back of my [mind] I would think, 'Is it because I took that medication?'" Rose said. "Being a mom, there's so much guilt wrapped up in it anyway, I didn?t want anything to be existing that I could blame myself for anything happening to her."

Rose's fears are not unfounded. Research on taking antidepressants during pregnancy has been mixed, with some studies showing a small risk and others showing no harm to the baby. In addition, few studies have looked at the potential effects to the child over the long term. However, over the last few years, more and more research has revealed untreated depression and anxiety also have potentially deleterious effects on the child, including a risk for preterm birth. So which is worse, having depression during pregnancy, or taking medication for it?

Researchers say it depends on the individual woman and the extent of her depression and anxiety. However, they agree many antidepressants aren't so dangerous that women should not take them if they need to.

"I think there's a myth out there that the medications are inherently bad during pregnancy," said Kathryn Hirst, director of the Maternal Mental Health Clinic at the University of California, San Diego. "When the reality is that depression and anxiety can be bad and cause significant problems in pregnancy and postpartum. And so for the mom, she really needs to look at what's worse, being depressed or anxious, and how that impacts me and potentially the baby, or taking the medication," Hirst said. "It really is a discussion a woman needs to have with an informed doctor or health care provider."

Medication during pregnancy
Between 14 percent and 23 percent of women will experience symptoms of depression during pregnancy, according to the American Congress of Obstetricians and Gynecologists. About 8 percent of women take antidepressants during pregnancy, according to a study published in 2006.

Most antidepressants have not been linked to an increased risk of birth defects, said Lori Wolfe, a genetic counselor and president of Organization of Teratology Information Specialists, a nonprofit organization that provides information to women about the use of medications during pregnancy. However, taking Paxil in the first trimester of pregnancy has been found to increase the risk of certain heart defects in babies by 1 percent above the natural risk. But later studies were unable to confirm the link.

Some studies have also found taking Paxil, Zoloft or Prozac in the third trimester of pregnancy may increase the risk for persistent pulmonary hypertension, a condition in which there are problems with the baby's blood circulation, and not enough oxygen reaches the bloodstream, resulting in respiratory difficulties, Wolfe said.

However, out of four studies looking at the risk for this condition, two have found an increased risk and two have not, Hirst said. More research is needed to clarify exactly what the risks of these antidepressants in the third trimester are, Hirst said. Such studies are important because, if it turns out these drugs do not pose a risk for persistent pulmonary hypertension, women who stop taking them in the third trimester may be putting themselves at an increased risk for postpartum depression for essentially little benefit.

"She's essentially off the medication at the time when she's at the highest risk for depression recurrence, which is right at postpartum, right at delivery," Hirst said.

Taking medications close to the time of delivery may mean the baby experiences some temporary withdrawal symptoms, including jitteriness and irritability, after birth. The symptoms usually last for about two weeks and go away without extra care, Wolfe said.

While some older antidepressants were linked to a risk of language and IQ problems, newer medications, known as selective serotonin reuptake inhibitors (which include Zoloft, Prozac and Paxil), have not been found to increase the risk of these problems, Hirst said.

Depression has harms as well
Experiencing major depression during pregnancy has been linked with an increased risk of preterm birth and lower-weight babies, Wolfe said. Premature birth itself is associated with a number of complications, including breathing and feeding difficulties.

Women who go off their depression medication may also be at risk for a relapse. A 2006 study published in the Journal of the American Medical Association found that, among women with a history of major depression who stopped taking medication, 68 percent experienced a relapse of their depression.

To cope with symptoms of withdrawal, these women may start to medicate with other substances, including illegal drugs and alcohol, "which is way worse than any antidepressant," said Adrienne Einarson, of The Hospital for Sick Children in Toronto, Canada. A 2001 study by Einarson found that many women who abruptly stopped taking antidepressants during pregnancy experienced adverse physical and psychological effects, including thoughts of suicide.
And if depression carries over to the postpartum period, it may affect the ability of the new mother to care for her child.

"The mother has to be in good health to be a good mother, you can't separate the two," Einarson said.

Studies have linked postpartum depression to behavioral problems and depressive symptoms in the children later in life, Hirst said.

Alternative therapies
One problem with teasing out the answer to "which is worse?" is that researchers cannot conduct rigorously designed studies to look at the question. These studies would involve randomly assigning depressed pregnant women to either receive medication or not during pregnancy. Such studies cannot be done ethically, said Tiffany Field, of the University of Miami Medical School. Researchers can observe what women do, but without random assignments, they run the risk that there is some other factor about the women who either choose or do not choose medication that can affect the results, Field said.

But researchers are trying to gain knowledge as best they can. Dr. Kimberly Yonkers, an associate professor at the Yale School of Medicine, is in the process of conducting a study comparing the effect of depression versus the effect of antidepressants on babies' health. The researchers made sure to find out exactly why the women in the study were receiving antidepressants ? whether it was for anxiety disorder or major depression, for example ? and how long they were taking it, factors that previous studies have not always included. So far, results have revealed that major depression by itself during pregnancy does not increase the risk for preterm birth or other major complications, Yonkers said.

"It does increase the stress and pain among moms, though, that is a major factor," Yonkers said. Ultimately, "I don't think the medications are so dangerous that people who have serious illness need to feel compelled to stop them," she said.

Some women may be able to manage depression and anxiety without medications by undergoing psychotherapy.

Rose sought alternative methods to relieve her stress, including exercise, napping and using essential oils. Herbal remedies cannot yet be recommended by physicians, Wolfe said, because there is no evidence that they are effective. But research is ongoing. Field is studying the use of exercise and yoga to reduce depression during pregnancy.

Rose and her doctor felt comfortable her choice was working for her. That does not mean the road was easy. "It just made it very difficult to deal with anything stressful," Rose said. "Little things could make me so upset. One time I cried so much I threw up."

Rose did not take medications during breast-feeding, but went on them for a period afterward. She is not currently taking depression medication and has a healthy 3-year-old girl.

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Global Moderator & Practitioner
I really liked that this article presents a balanced view of some of the factors that go into deciding about antidepressants in the context of pregnancy. I think that it does a great job of considering pregnancy from the first trimester thru delivery. But here's a piece that caught my eye:

Medication during pregnancy
... However, taking Paxil in the first trimester of pregnancy has been found to increase the risk of certain heart defects in babies by 1 percent above the natural risk. But later studies were unable to confirm the link....
While some older antidepressants were linked to a risk of language and IQ problems, newer medications, known as selective serotonin reuptake inhibitors (which include Zoloft, Prozac and Paxil), have not been found to increase the risk of these problems, Hirst said.

Birth-Defect Data Show SSRI Risks Are Minimal

Current psychiatric practice in large metropolitan areas (in the US) would likely not follow what is implied from Hirst has said - in part because of the work from the New England Journal of Medicine (july 2007) that finds a "small, but notable" correlation between sertraline (Zoloft) and congenital heart defects. In fact, if you actually read the study, the odds ratio for those babes exposed in utero, during the first trimester, is significantly higher for heart defects, than those not exposed. "Small but notable" in research translates into ".... hardly ever worth the risk", in practice. So, in general, it likely would be very unusual to now find a woman in her first trimester, on Zoloft. Certainly the other SSRIs are used - although I also know that psychiatrists will also avoid paroxetine (Paxil) ... and many avoid using Prozac (fluoxetine) for unrelated reasons. In practice, for a woman who must be on antidepressants in the first trimester, fortunately, there are ones available that are either not SSRIs or are combination meds so that the levels of seratonin are not raised quite as high (at least, in theory, because we really can't measure it).

But the rest of the article makes many good points - indeed, from a perspective of "meds or no meds", it often comes down to factors like severity of symptoms, available support, insight and ability to quickly garner additional help if needed, and past history. This is particularly true in the first trimester - when organ systems are being formed. Sometimes a woman can be supported thru the first trimester with frequent meetings, social support, adjunctive therapy etc. But sometimes not.
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