Are Antidepressants Safe to Take During Pregnancy?

Are Antidepressants Safe to Take During Pregnancy?

You'll definitely want to talk to your doctor about this.

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.

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, depending on the circumstances of one’s condition—including severity, duration and history of depression—the dangers of untreated depression may outweigh the potential risks posed by the drugs.

Amy Motamed, DO, a psychiatrist at Medical City Green Oaks Hospital in Dallas, Texas, has treated many pregnant women with severe depression. Her opinion is that women’s 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 it may be challenging for patients to understand the overlapping symptoms of pregnancy and depression.

“A lot of symptoms of depression—like low appetite, fatigue, change in sleep habits—can also be consistent with a normal pregnancy, 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 receive 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 birth weight and complications after birth. More ominously, pregnant women with untreated depression may also be at increased risk of suicide.

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 in an outpatient setting is typically psychotherapy, Motamed says. “That usually means either cognitive behavioral therapy or interpersonal therapy.”

There are also situations in which antidepressants are recommended for patients with mild to moderate depression: in cases when talk therapy has proven ineffective, unacceptable or is unavailable to patients; when patients have a previous history of severe depression or have had multiple past relapses of depression; or when patients prefer antidepressants because they’ve helped them in the past.

All told, 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, though, 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 considered 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.

When studies look backwards on self-reported habits, rather than isolating specific medications, other health factors—such as a woman’s diet or her use of alcohol, tobacco and other prescription medications—may influence the results. Some studies may also compare pregnant women with mental illness who took antidepressants to pregnant women who were healthy, which can muddy a clear comparison between pregnant women with depression who took antidepressants and those who did not.

Some antidepressants present concerns
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. But one SSRI in particular, paroxetine, poses some concerns for pregnant women.

A 2015 analysis by the CDC that looked at previous studies described associations between paroxetine and defects of the brain, skull, heart and abdomen. Previous studies have identified a link between paroxetine exposure and cardiac defects, though other studies have found no such risk.

Although the data linking first trimester use of paroxetine with heart defects are not generally deemed strong, the link was significant enough to lead the US Food and Drug Administration to require a warning that pregnant women taking paroxetine should be advised of potential harm to the fetus.

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 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.”

Other classes of antidepressants—such as tricyclic antidepressants (TCAs) and selective serotonin and norepinephrine reuptake inhibitors (SNRIs)—are less commonly used in pregnant women than are SSRIs, but they still may be prescribed if your doctor determines that the benefits of treating your depression outweigh any risks potentially posed by those drugs. 

“No two people are the same,” says Motamed. “If you're severely depressed, if you've had multiple episodes of depression, I would absolutely advocate for therapy and medication as needed.”

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 to induce a brief seizure under anesthesia.

The importance of treatment
It's crucial to recognize that there is no one-size-fits all prescription for treating depression, and the key is to work closely with your doctor to develop a treatment plan that weighs the benefits of treatment against the potential risks posed by medications. 

Untreated severe depression is linked to poor nutrition, substance abuse, poor prenatal care, postpartum depression and impaired relationships between the mother and her infant. Patients who are severely depressed also have an increased risk of suicide.

“Patients may be reluctant to talk about having troubling thoughts, such as wanting to hurt their baby or themselves,” says Motamed. "They may feel badly that they're having these thoughts, as pregnancy is generally thought of as a happy time."

That said, Motamed notes that it's extremely important for providers to ask patients if they've had any of these types of thoughts, especially if they've had a previous psychotic episode or a severe depressive episode in the past.

Regardless of the treatment method used, the key is to stick to a plan 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 program 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.

Medically reviewed in May 2018.

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