Most of us can point to depressing episodes in our lives….woes befall all of us: the economy, personal loss, worries about errant spouses, children (remember, we are only as happy as our most unhappy child) and aging parents. And I haven’t even begun to list the enormity of the global energy problems, international conflicts and consequences of disease. (If I keep going, I’m bound to find something that depresses you!) There is, of course, a difference between having to deal with either personal or large scale social issues that lead to sadness and worry and the occurrence of true clinical depression. The best way to define the latter, without going into treatises put out by the American Psychiatric Association, is that nothing gives you pleasure; nor can you function in your everyday mode of life. If you feel that you are in a dark tunnel with no light at the other end, day after day; you are clinically depressed. And a huge number of us are… up to 25% of women develop clinical depression at some point in their lives (more then twice the prevalence of clinical depression in men, which may be a reflection of our genetic capacity for concern and sensitivity).
Clinical depression peaks in our reproductive years. Nine percent of women will have an episode during or within 3 months of pregnancy. The consequences can be harmful to both mother and child. There are entire medical journals dealing with “the safest way” to deliver a baby, the pros and cons of Cesarean vs. natural delivery, the concerns about vacuums, forceps, routine episiotomy, not to mention tables to ascertain desired weight gain, concerns about preterm deliveries and of course tests to ensure the genetic integrity of our offspring. But few Ob Gyns are trained to either recognize or treat clinical depression in pregnancy. When asked by a patient whether it is safe to start or continue antidepressant medication during pregnancy….we hem and haw. Here is what I now tell my patients:
Women are more apt to develop depression during pregnancy if they:
- Have a history of depression at any time including a previous pregnancy or postpartum.
- Have been diagnosed with clinical depression in the past.
- Have a family history of depression, especially during pregnancy or postpartum.
- Have other psychiatric illnesses (panic disorder, obsessive-compulsive disorder, bipolar disorder, substance abuse).
- Marital instability…this cover a lot of issues, I translate it as a non supportive, or worse yet, abusive spouse.
- Unplanned pregnancies …unfortunately as many as 50% of pregnancies are not planned).
Depression can harm a pregnancy:
Studies have shown that women who are depressed during pregnancy have twice the risk of cesarean section, premature delivery and neonatal intensive care admissions of the newborn as well as four times the risk of delivering a low birth weight infant when compared to women who were not depressed. Depression and severe stress can cause changes in the hormonal environment in which the fetus is developing (This includes steroids such as cortisol, maternal brain hormones, estrogen, progesterone, insulin and growth hormones to name a few). The theory is that this “upset” hormonal milieu can impact fetal growth and fetal programming so that the infants, especially those born at lower than expected birth weights to women who were significantly depressed or stressed during their pregnancy are at future increased risk for schizophrenia, cardiovascular disease, type 2 diabetes osteoporosis and depression.
Treatment: Is it Safe in Pregnancy?
All psychiatric medications cross the placenta. If a pregnant woman is mildly or even moderately depressed (a brief definition: she has no thoughts of suicide, has not needed medication for depression in the past and is able to continue her usual functions) then traditional psychotherapy may be all she needs to successfully deal with her depression. (And we have all become more familiar with therapy sessions after watching Gabriel Byrne). But if her depression is moderate to severe and medication has helped in the past, her best option would be pharmacologic….i.e. antidepressant medication. And the current recommendation is to use the drug that previously worked. Clinical depression is a medical disorder that, like diabetes or hypertension can adversely affect the outcome of pregnancy…not treating it will create a greater risk for a woman and her unborn child than treating it. There has been a reluctance to include pregnant women in many pharmaceutical studies conducted in the past, but as the need to address depression in all women becomes apparent, antidepressants are now being investigated for use during pregnancy.
SSRI’s (Selective Serotonin Reuptake Inhibitors)
There are many….each with a slight change in chemistry, indication and side effects. Medications in this category include Zoloft, Paxil, Celexa, Lexapro, Effexor, Cymbalta, Wellbutrin, and Serazone. As I write this, more are being introduced. Multiple studies have shown there is a very low absolute risk of congenital anomalies when these medications are used during pregnancy. But the pharmaceutical companies and prescribing physicians must include appropriate reports of adverse effects….sort of like the list of everything that can go wrong at the end of those direct-to- consumer ads you see on television (usually stated in a hurried, breathless manner by a male voice) or read in the patient information provided with the prescriptions.
So here are some: There have been studies that describe an increased risk of abdominal and skull defects with first trimester use of SSRI’s and a rare cardiac defect with Paxil. (Although a Canadian study contradicted the latter.) There has been no evidence of fetal malformations due to use of Prozac in pregnancy…this is indeed the most studied (and oldest) SSRI.
There maybe a sight increase in miscarriage rates among women who take antidepressants compared to nondepressed women: 12.5% v. 8.7%. (It’s difficult to establish if this is due to the meds or their underlying depression). There are also reports that third trimester exposure to SSRI’s can cause tremor, breathing, sleeping and feeding problems in newborns, but this is usually mild and disappears after 2 weeks. The long term good news is that these medications appear to have no effect on exposed children’s IQ, language development or temperament.
Benzodiazepines (such as Valium, Xanex, Dalmane, Ativan, Klonipen. Restoril)
There have been studies that may have shown an increase in cleft palate in infants exposed to benzodiazepines but other studies have not… quite frankly the literature is not definitive.
This is considered relatively safe during pregnancy: but it may increase an exposed infant’s risk of a rare cardiac valve problem. The recommendation is to stop lithium 24 hours before delivery.
To Summarize: If you are on a medication for depression that works, especially an SSRI and you conceive….keep taking it. If you stop, chances are you will have a relapse and this can harm you and your pregnancy. Know that you may need higher doses as the pregnancy develops. (There are a lot of changes in the metabolism and dilution of any medication as you and your pregnancy grow.) After 4 to 6 weeks you and your doctor may decide you need to increase the dose every 2 to 3 weeks until your symptoms are in remission.
Every time the media reports on a new adverse effect from an antidepressant….remember that bad news makes news. If you suffer from clinical depression before or during pregnancy, treatment can make a very positive difference in your pregnancy outcome and the future health of your child.