Reading Beyond the Headlines: A Closer Look at the Study on Antidepressants During Pregnancy

A recent study regarding the use of antidepressants has been gaining a lot of media attention. The actual study, The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond (Domar, Moragianni, Ryley & Urato, 2012) has been described by media with a fair amount of fear-based headlines. Safety regarding the use of a specific type of antidepressant medication, selective serotonin reuptake inhibitor (SSRIs), is an important topic of research,  as care providers from many fields address the prevalence and negative effects of depression and other mood disorders in pregnancy.

 

Understandably, pregnant women and their families may be greatly alarmed by these dramatic press releases, and in some cases may consider suddenly discontinuing their medication, without realizing the significant risks that accompany suddenly stopping medication. What do the experts say?

 

I asked the study’s lead researcher, Alice Domar, MD what advice she would offer a pregnant woman who is currently on one of the SSRI medications listed in the study to do, and she kindly offered this response:

 

I would never recommend the sudden discontinuation of an SSRI during pregnancy. There are significant side effects associated with the abrupt cessation of antidepressants and we don’t know the impact on the developing fetus. The three main points we were trying to make with the paper were: 1) there are risks associated with taking SSRIs during pregnancy, 2) there are no clear benefits, and 3) each patient needs to have a discussion with her physician about her individual risk/benefit ratio.  There is a huge difference between a woman who is suicidal, who in all likelihood should remain on medication, versus women with mild or moderate symptoms who would benefit from a different approach, such as cognitive behavioral therapy, or physical exercise, both of which are very effective in the treatment of depressive symptoms.” –Alice Domar, MD (personal email communication, 11/2/12)

 

Another of the study’s researchers, Dr. Adam Urato, offered this follow-up:

“Your question is a good one (What would you advise a pregnant woman who is currently on one of the SSRI medications listed in the study to do?) and it is one I deal with several times each week as an Maternal-Fetal Medicine specialist.  I agree with Dr. Domar’s comments.  Sudden discontinuation of the SSRIs is not recommended.  They should be tapered for those who plan to discontinue them. The patient and their pregnancy health care provider (and their mental health provider) need to be aware of the scientific evidence regarding these drugs.  That evidence shows significant risk of pregnancy complications (like miscarriage and preterm birth) and no evidence of benefit for moms and babies.  In non-pregnant populations, alternatives like cognitive behavioral therapy and exercise appear to be as effective as the SSRI antidepressants and without the side effects and pregnancy risks.” (Personal email communication, 11/2/12)

 

Reaching out to experts in the field provided roundtable perspective. Christina Chambers, MPH, PhD, California Teratogen Information Specialist (CTIS) and director of the Pregnancy Health Information Line, had these thoughts:

“I agree with the authors’ comments. Caution is warranted, treatment makes sense when benefits are clear, and women with less severe illness might consider alternative approaches if they work, abrupt discontinuation without doctor’s advice is not a good idea, and care needs to be taken to address the issue of complications for mother and baby of untreated or poorly treated maternal depression. If a woman has questions, she should consult her doctor. She can also call the Organization of Teratology Information Specialists (OTIS) at 866-626-6847 to speak to an expert in this field.” (Personal email communication, 11/2/12)

 

Lucy Puryear, MD, immediate past president of Postpartum Support International (PSI) and Medical Director of The Women’s Place: Center for Reproductive Psychiatry offered:

“For women with mild to moderate depression psychotherapy and alternative treatments are absolutely the first choice. But for women with moderate to severe depression that is impairing functioning, antidepressants must be an option. Antidepressants do work in this population and save lives. Our challenge is to continue to look for the safest and most effective treatments for women during this vulnerable period.” (Personal email communication, 11/2/12)

 

PSI’s Executive Director Wendy N. Davis, PhD, agreed,

“We are most concerned that women will be unduly frightened by articles that discuss risks of antidepressants but do not discuss positive experiences or research studies that show little statistical relationship between SSRI use and pregnancy outcome. We want to connect women with reliable resources and experts in perinatal psychiatry so they can make thoughtful decisions about treatment options for depression and anxiety during pregnancy.”

 

A word about the science….

One of the pre-eminent researchers in the field, Adrienne Einarson of The Motherisk Program, shared some important criticisms of this study:

Here are my main problems with this publication:

1) It is said to be a review on treatment for infertility patients, however, one-third of the paper is about the lack of efficacy of antidepressants in general.
2) To say there is no evidence for effectiveness in pregnancy is true, but that is simply because there are no RCTs (randomized control studies), not because this has been proven.
3) All of the studies that were picked were ones that found negative effects, with no mention of how marginal the statistical significance really was.
4) The paragraph that is the most concerning is the one starting with “There is compelling evidence that SSRI use prior to and during pregnancy can pose significant risks to the pregnancy and to the short- and long-term health of the baby…” Of course there is compelling evidence when you choose your studies to fit your hypothesis.

This was a biased review, not a systematic one as reviews should be. In fact, there was not a single study referenced in this paper that did not find any harmful effects when there are many that have been published. (Personal email communication, 11/4/12)

 

When I was pregnant with my daughter, I had a sinus infection. I went to a general practitioner for treatment and shared that I was on an SSRI. You would have thought I told her I was shooting heroine every hour on the hour while tossing back jello shots and chain smoking! If I hadn’t had the science from my research treatment team at the UCLA Women’s Life Center, I could have easily been scared into stopping my medication. Instead I pulled out a collection of evidence-based research I carried in my purse and left it with her.

 

Unfortunately, for a woman who is pregnant and has depression, trying to decipher headlines and the seemingly constant stream of warnings might be overwhelming. Not to mention the stigma that accompanies depression and motherhood. Most don’t realize that to be that mom means you have to be constantly armed with proof that you are not harming your child. This is where having Adrienne Einarson’s insights can help you navigate the science, and advocate for your health and well-being.

 

Take Home Message:

If you are currently pregnant and taking an SSRI, do not abruptly stop taking your medication until you talk health care provider about risks and benefits for your individual care. If you feel you may be experiencing depression or anxiety and are pregnant, you deserve help with your symptoms. Not getting help has been proven to have negative effects on a developing fetus and increases the risk of pre-term birth, lower birth weight, and postpartum depression. Discuss your symptoms with your care provider immediately. I highly recommend using the resources available at OTIS (866) 626-6847 to address your concerns and questions.

 

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Walker would like to thank Alice Domar MD; Adam Urato, MD; Christina Chamber, PhD, MPH; Lucy Puryear, MD; Wendy Davis, PhD; and Adrienne Einarson for their contributions.

 

Reference

Domar, A. D., Moragianni, V. A., Ryley, D.A., & Urato, A.C. (2012). The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond. Human Reproduction, Vol.0(0) pp. 1–12 doi:10.1093/humrep/des383

 

Other Resources:

Department of Health and Human Services: Depression During and After Pregnancy: A Resource for Women, Their Families, & Friends

Pregnant with Disabilities: Depression

Today’s post is the second in this week’s series devoted to pregnancy and disabilities. Giving Birth with Confidence is contributing these posts as part of the Bloggers Unite event, People First: Empowering People with Disabilities. The blogging event aims to raise awareness about empowering people with disabilities by sharing stories around the ‘Net in support of people with disabilities and the groups who work to empower them.

Sherean is mother to a 20-month-old happy and healthy boy named Hunter and lives with on-again, off-again depression. Her post talks about dealing with and treating depression during her pregnancy. Sherean blogs at Random Neural Firings.

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There’s a lot of press about postpartum depression. I mean, who hasn’t heard of Brooke Shields squaring off against Tom Cruise over it? I was prepared for postpartum depression. I’d struggled with depression before, mostly in my 20’s, but some in my 30’s, and knew that put me at a higher risk.

What I didn’t know is that you can also get depression DURING pregnancy — perinatal depression, it’s often called. I got it, big time, along with a big wallop of anxiety. So bad I had to see a psychiatrist and was treated for it with medication. Of course, this made me feel guilty and like I was going to hurt my baby. The doctor explained that the risks with the medication weren’t known, but they did know the damage that depression and anxiety could do to a developing fetus. Small comfort, right?

I took the meds and cried. My husband was wonderfully supportive. By mid second trimester, the hormones that were causing those problems went away, I guess, and I felt better. Just like the psychiatrist predicted. But the fact that I had depression during pregnancy put me at an even higher risk for postpartum so we were vigilant, watching for signs. Fortunately, I dodged that bullet.

I felt like such a bad pregnant woman. I hated being pregnant. I felt sick: you name it and I got it. I even got RLS (Restless Leg Syndrome) in pregnancy. The physical problems on top of the depression made for a pretty unhappy time. I remember crying on the couch and feeling soooo guilty that I wasn’t feeling happy. Everyone’s happy when they’re pregnant, right?

I knew I had depression and I knew it was triggered by something in my chemical stew. I’d been pregnant twice before (miscarriages); one pregnancy made it to 11 weeks and I didn’t have anywhere near this kind of anxiety. So the minute I sorted out that this wasn’t “normal” pregnancy hormone stuff, I marched my butt to my Ob and said “help.”

My son was born completely happy and healthy. I was thrilled and am thrilled every single day. He is such a delight. I can barely remember what it was like when I was pregnant to curl up on the couch and not want to read or watch TV or eat. It really is hard to remember, even though it wasn’t that long ago. It’s like once the happy hormones kicked in, I developed amnesia about how awful it all was. I would not wish that on anyone. I agreed to be interviewed and photographed for a piece in the New York Times on the subject, because I hope if you’re struggling, you’ll speak up, too. There is help. You will get through it and you will get better.