Research suggests that depression is diagnosed twice as often in women as it is in men, and it typically presents during a woman’s childbearing years. It’s no surprise, then, that depression is fairly common in pregnant women, affecting an estimated 14 to 23 percent of moms-to-be.
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But because pregnancy is a delicate time for both mom and a developing fetus, many women are concerned about the impact antidepressants may have on their babies.
While experts recommend avoiding certain types of antidepressants, many medications for depression are considered low-risk for pregnant women when compared with the alternative of not adequately treating depression. In other words, the dangers of untreated depression may outweigh the potential risks posed by the drugs.
Psychiatrist Amy Motamed, DO, has treated many pregnant women with severe depression. She wants to make sure women know that their first priority should be to treat their mental illness – for their own sake and for that of their babies.
Getting a good diagnosis
The first step to treating depression is to get a sound diagnosis, but that can be challenging for doctors treating pregnant women.
“A lot of symptoms of depression – like low appetite, fatigue, change in sleep habits – can also be signs of being pregnant, particularly in the first trimester,” Dr. Motamed says.
In order to diagnose depression, Motamed makes it a point of getting to know her patients and speaking to family members and others involved with the pregnancy. She’ll also ask her pregnant patients a series of questions to try to tease out the specific issues, including:
- Have you been pregnant before?
- Was there a time when you weren't depressed?
- How does this feeling compare to how you felt during a previous pregnancy?
Understanding the need for treatment
Before even going over a patient’s treatment options, Motamed says it’s critical to help a patient comprehend the risks of not treating her depression. For example, many pregnant women with untreated depression don’t get adequate prenatal care – they don't eat well and may not get enough sleep.
Pregnant women with untreated depression may also be more likely to smoke, drink or use drugs. “They’re often self-medicating,” Motamed notes.
For reasons such as these, depression during pregnancy has been linked to premature birth, low birthweight and complications after birth.
What treatments are recommended?
Treatment for pregnant women – as for non-pregnant woman – will depend on numerous factors including the severity of the depression, the strength of a patient’s support network and her comfort level with different kinds of therapies.
For mild to moderate depression, especially for first-time episodes, the first line treatment is typically psychotherapy, Motamed says. “That usually means either cognitive behavior therapy or interpersonal therapy.”
There are also situations in which antidepressants are recommended for patients with mild to moderate depression. An estimated 6 percent of pregnant women fill prescriptions for antidepressants, according to 2013 data compiled by the Centers for Disease Control and Prevention (CDC).
Research into risks is not definitive
Because a fetus gains exposure to antidepressant medication as it crosses the placenta and circulates in the amniotic fluid, Motamed explains, the medication can potentially have effects on the developing infant. This can be concerning to many women.
Unfortunately, it’s difficult to pin down exact linkages between antidepressants and fetal issues because research protocols do not permit experimenting on pregnant women.
“The gold standard to assess whether or not a medication has side effects is a randomized control trial,” Motamed explains. “But you can't do those trials in pregnant women because it's not ethical.”
As a result, she explains, the data available on antidepressants and pregnant women is typically based on reports that patients provide to researchers after pregnancy. What’s more, those studies that have been done can yield only associations – not cause and effect relationships – between the use of antidepressants and fetal issues.
Concerns about birth defects
For certain antidepressants, some of the concerns raised by research have persisted across multiple studies and may be worth taking into account when you consult with your doctor about treatment for depression.
Selective serotonin reuptake inhibitors (SSRIs) are far and away the most commonly prescribed antidepressants for pregnant women, just as they are in the population at large. Most SSRIs are considered lower-risk for use by pregnant women, and the most frequently used SSRI, sertraline, is believed to present minimal concerns. But two SSRIs in particular – fluoxetine and, to a greater extent, paroxetine – have raised some red flags.
Most doctors prefer not to prescribe paroxetine to pregnant women. But in some cases, the benefits of effectively treating depression may outweigh potential risks to the baby.
“We try to avoid paroxetine if we can,” says Motamed. “But if a patient tells me she’s taken three other medications and the only time they've had any response was to paroxetine, it may make more sense to stay on it.” The key, she says, is to give the patient full access to the information available and help them make the best decision for their situation.
“If you have a patient who's moderately depressed and they've had a previous severe depressive episode or psychotic symptoms,” Motamed says, “I would be hesitant to advocate for changing their medication, even if that drug is paroxetine.”
If a patient is already taking paroxetine and switches to another medication, the fetus has now been exposed to the two drugs. “And if that patient doesn’t respond to the new drug,” Motamed explains, “they may end up needing to go back to paroxetine anyway.”
Some research also links tricyclic antidepressants (TCAs), particularly clomipramine, to fetal heart defects, but that risk is considered to be low with most studies not showing a link. TCAs are not commonly used as a first line treatment in pregnant women.
Other antidepressant-related worries
Less concerning, but still worth noting, is evidence that preterm delivery is more likely in women who use SSRIs and TCAs. Both classes of drugs, particularly when taken late in pregnancy, are also associated with mild jitteriness and irritability in newborns, but those symptoms typically go away within two weeks after birth.
Postpartum hemorrhage in the mother is also a potential side effect of taking paroxetine at the time of delivery, as well as certain serotonin and norepinephrine reuptake inhibitors (namely duloxetine or venlafaxine) and TCAs.
Most recently, a study published in April 2018 in JAMA Pediatrics suggests that SSRI use may influence fetal brain development by leading to increased grey matter volume in certain areas. But the exact effect – and whether it constitutes a danger – is unclear.
One non-drug option for patients with severe depression who fail to respond to antidepressants is electroconvulsive therapy. The procedure involves running small electric currents through the brain, and is regarded as effective and safe for both mom and baby.
Stay consistent in your treatment
All in all, experts agree that pregnant women with depression should not avoid treatment out of concern over the potential effects on an unborn child, since those effects are not clearly understood. Regardless of the method used, the key is to stick to a treatment that works and only change or taper off treatment under the supervision of a mental health professional.
“If you suddenly stop a medication without an improvement in your condition, your risk of relapse goes up and the baby may thus be exposed to both the medication and the potential effects of depression,” Motamed explains.
Ultimately, whether antidepressants are part of your treatment plan or not, the goal is to help you have a healthy and happy pregnancy. “We want to make sure a patient is sleeping well, eating well, exercising, going to therapy and optimizing their support,” says Motamed.
After all, you’ll need to be at the top of your game and able to weather a host of new stressors when it comes time to deliver your baby – and when you have a new little one at home.