Antidepressants in Pregnancy: Yay or Nay?
This blog post is written by Dr. Amanda Goldstein, a board certified psychiatrist and Dr. Madeline Kaye, an obstetrician/gynecologist, from our wonderful friends at ThreeMDs, a blog that provides easily digestible, evidence-based, and integrative medical information.
“I want to have a baby. Should I stop my antidepressant?”
Before we jump into answering this question, we just want to take a moment and congratulate you on making this incredible decision! If you are not pregnant yet, then you are fortunate to have some time to plan and make important choices about what you want your pregnancy to look like. If you are currently pregnant and taking an antidepressant, this article still applies as many women start and stop medications throughout pregnancy for numerous reasons.
In an ideal world, where problems don’t exist, we would eat perfectly clean diets, move our bodies every day, and be positive and calm all of the time. I’m sorry to tell you this, but despite what you see in placid Instagram photos, this is a rare occurrence. And even if you do everything perfectly, some people are just prone to depression and/or anxiety (thanks, mom and dad). Pregnancy is a time of many physical, mental, and biochemical changes, which means it is a vulnerable time.
Selective serotonin reuptake inhibitors (SSRIs) are the most commonly used class of antidepressants, and are used to treat both depression and anxiety (as well as a few other conditions). If an antidepressant has made a huge difference for your mood and anxiety, then it is absolutely worth considering continuing during your pregnancy. It’s your body and your pregnancy and only you know how much you can handle. But we want you to have all of the information, so you can feel confident in your decision. Everything comes down to weighing the risks and benefits.
What are the risks of being depressed during pregnancy?
Untreated depression not only affects mood, but also sleep, energy, concentration, motivation, appetite, and activity level. When you’re not at your best, you may forget to take your prenatal vitamins, miss your doctors’ appointments, and make unhealthy lifestyle choices. When you are in a sustained state of low mood and/or high anxiety, you have more cortisol (as well as changes in other hormones and neurotransmitters) floating around, which can affect your growing baby. This can lead to an increased risk of obstetrical and neonatal complications, including preterm birth, low birth weight, pre-eclampsia, and intensive care unit admission. Furthermore, postpartum depression can impair normal attachment and bonding, which can alter the cognitive and behavioral development of your baby. (Future article to come on postpartum depression and anxiety.)
What are the risks of taking an SSRI during pregnancy?
There are a lot of conflicting studies out there, and it is often difficult to determine whether problems are from the antidepressant or the depression/anxiety itself.* Early studies raised concern for a condition called persistent pulmonary hypertension of the newborn, which is a serious medical condition in which the blood vessels to the lungs are narrowed, causing breathing difficulty. About 0.2% of babies are born with this condition. Some studies show that the rate is no different if antidepressants are involved, but some show an increased rate of about 0.4%. This is a very small increase, but still something to consider. There is similar conflicting evidence about fetal malformations. Older studies suggested an association between a specific antidepressant, paroxetine, and cardiac defects. Again, the increase in risk reported by these studies was very small, and newer and better designed studies show no increased risk.
Up to 30% of babies exposed to antidepressants experience poor neonatal adaptation syndrome (previously called neonatal withdrawal syndrome), which usually presents a few hours after birth and resolves on its own within 2 weeks. Symptoms are usually mild, but can include jitteriness, irritability, feeding difficulty, and respiratory distress. This can be distressing for the parents, but it is comparable to infantile colic and there have been no reported cases of mortality. The best treatment includes a quiet environment and skin-to-skin contact.
*Note that nearly all of these studies have been done with SSRIs. There are other classes of antidepressants that are less studied or have different risks. Bipolar depression is treated with different medications that have their own set of risks.
If you are considering becoming pregnant and you currently take medications (any medications, not just antidepressants), then you should discuss your game plan with your doctor. If you and your doctor decide to stop a medication, it may take several weeks to slowly taper the dose. You do NOT want to go cold turkey off of antidepressants or you will feel like crap!
If you and your doctor decide to stop your antidepressant, we highly recommend continuing or starting psychotherapy, which is an effective and safe treatment option for mild to moderate depression. This also ensures that a healthcare provider is keeping a close eye on you and monitoring your symptoms. There is also growing evidence that yoga, massage, acupuncture, and light therapy can be helpful. And if therapy is not accessible or symptoms are more severe, continuing or starting an SSRI is generally your best bet for you and your baby’s health and safety.
We hope this article helps to clarify some of the confusing information out there and makes this personal decision a little bit easier.
Love from Team OBGynechiatry,
Dr. K and Dr. G
