Up to 20% of women experience at least one episode of clinical depression in their lifetime. Talking to my patients and surveying my family, I sometimes think it might be even more than that… But I will cheerfully tell you about an article that came out in the New England Journal of Medicine on June 19. (The day before my birthday, a somewhat depressing event although I kept telling myself that aging is a privilege.) The article was titled “Antidepressants on Pregnancy and Risk of Cardiac Defects”.
According to the authors from the Department of Medicine at the Brigham and Women’s Hospital and Harvard Medical School, clinical depression occurs in 10 to 15% of pregnant women. The use of antidepressant medications during pregnancy has increased and is now reported to be 8 to13% in United States.. The chief concern is use of these meds in the first trimester pregnancy when potential teratogenic effects are more likely to occur, especially cardiac malformations. There been many studies that tried to address this issue and indeed on the basis of early results of two epidemiological studies, the FDA warned physicians that early prenatal exposure to Paxil could increase the risk of congenital cardiac malformations. Since then, however, other studies have been done with conflicting results and there is still significant controversy regarding whether this is (as the authors put it) “a serious concern or much ado about little.”
The current study published last week used a large national database of women from 46 U.S. states and Washington D.C. who were insured through Medicaid and were pregnant and delivered during the period between 2000 and 2007. Apparently this included close to 950,000 pregnancies. (Just so you know, Medicaid covers the medical expenses for more than 40% of births in the United States!). During the first trimester, 64,389 women or 6.8% used an antidepressant. The most common were Zoloft, Paxil and Proxac. When the researchers restricted their study to women with a recorded diagnosis of depression, they found that there was no increase in the risk of cardiac malformations among infants born to women who took the antidepressants during the first trimester as compared with infants whose depressed mothers did not. Other studies had not done this, they simply compared women who took antidepressants in pregnancy to those who most likely were not depressed and didn’t need them. The authors pointed out that in restricting the study to women with a recorded diagnosis of depression they have corrected for the potential influence on pregnancy of underlying psychiatric illness and associated conditions and behaviors which could increase the risk of malformations. These include smoking, alcohol and illicit drug use, poor maternal diet, obesity, diabetes and hypertension all of which are more common in women with depression than in those without. They also pointed out that women with depression and anxiety are more likely to use health care resources and hence there’s a higher chance of detecting a cardiac malformation in an infant who has a minor malformation that might otherwise have remained undetected and even self-corrected in early childhood.
Their conclusion: the use of antidepressants during the first trimester does not substantially increase the risk of cardiac malformations. They then add the phrase that is applied to just about every medication used in pregnancy. “In making decisions about whether to continue or discontinue treatment during pregnancy, clinicians and women must balance the potential risks of treatment with the risk of not treating”… In this case severe depression.
Although many of my readers are not pregnant, they may have used antidepressants in past pregnancies and worry about potential consequences an/or they have friends and family who will need to consider using antidepressants in current or future pregnancies. This study gives reassurance.