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.

 

____________________

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

Pregnancy and Asthma

By Nadia Mohamedi, OTIS Teratogen Information Specialist

                As a teratogen information specialist at OTIS, I frequently hear the same scenario regarding pregnancy and asthma. A mom is so excited that she is being “safe” in her pregnancy because she has come off all of her asthma medications. She is almost completely out of breath, exhausted from wheezing all night, and extremely limited in the activities she can still do. Despite her own suffering, she is proud of her heroic acts in saving her developing fetus from potential harm. Unfortunately, like many other breathless moms, she has been misinformed about the effects of asthma and asthma medications in pregnancy… and the truth often leaves her feeling a lot less like a hero.

The Breadth of Breath

Everyone knows that breathing is crucial to life, but do we really understand why? Let’s re-visit the basics. Breathing delivers oxygen to our lungs, where the oxygen is transferred to our blood, brought to the heart and then pumped out to all the cells in our body.  In fact, oxygen makes up 65% of our body mass!

Oxygen is crucial to a cell’s normal metabolism. Cells use oxygen as their primary source of energy. With oxygen, cells are able to carry out all of their marvelous acts like re-building old tissue, disposing of waste, and creating new cells. Without enough oxygen, our cells become weak and are more susceptible to viruses.

Cells that rely more heavily on oxygen to survive are the cells in our brain. While the brain only makes up 2% of our body weight, it uses up 20% of our oxygen. So, oxygen is also necessary for our mental processing, like memory, movement and thought. Brain cells are so sensitive to oxygen that they begin to die after a few minutes without it.

Asthma is caused by an inflammation in the air passageways, which prevents air from being able to enter the lungs. Thus, asthma is a serious condition that causes a person to take in less oxygen than they may need.

Breathing for Two

While not as fun as eating for two, it is important for pregnant women to remember that they are their babies’ only source of oxygen. If a mom’s asthma is not controlled, both she and her baby are getting less oxygen. Although babies do not take their first breath until they are born, in utero they receive all their oxygen from the placenta (the blood connection between mom and baby).  Now that we know how crucial oxygen is to life, it’s probably clear why a fetus that develops from a single cell to a full-functioning human needs it. In fact, untreated asthma is considered to be riskier than asthma controlled with medications in pregnancy. Here is why:

  1. Mom’s risk: Untreated asthma during pregnancy increases the mother’s risk for pre-eclampsia (a group of symptoms including high blood pressure, ankle swelling and kidney problems), excessive vomiting, vaginal bleeding, and premature and complicated labor. In fact, the more severe the asthma is in pregnancy, the more likely a pregnant mom will be hospitalized during pregnancy.
  2. Baby’s risk: Untreated asthma during pregnancy increases the baby’s risk for slowed growth, preterm birth (before 37 weeks gestation), and even death.

Just Breathe…Through Your Inhaler

You are not alone. Asthma affects 8% of all pregnancies. Although one-third of women experience an improvement of asthma during pregnancy, about one-third of women get worse. Asthma can also become worse in the second or third trimesters as your belly pushes up against your diaphragm, making it harder to breathe. Thankfully, while severe asthma is associated with more severe risks, better-controlled asthma is associated with lower risks. Thus, most asthmatic pregnant women will need to take a medication to adequately control their condition.

Most asthma medications have not been shown to have harmful effects on the baby. The majority of women can control their asthma by taking an inhaled medication like albuterol or an inhaled corticosteroid. Inhaled medications act directly on the air passageways to decrease inflammation and open them up for breath. Because inhaled medications are not meant to be absorbed and distributed throughout the body like a pill you swallow is, very little of inhaled medications are absorbed into your blood and able to go to your developing baby. Thus, inhaled medications are usually considered to be of a low risk to the baby.

Information about specific medications (albuterol, prednisone/prenisolone, inhaled corticosteroids, formoterol, salmeterol and montelukast) can be found on the OTIS Fact Sheet page on our website: http://www.otispregnancy.org/otis-fact-sheets-s13037. You can always call OTIS for individual risk/benefit analysis and speak with a counselor (like me J) directly by calling toll-free 1-877-311-8972.

Super Oxygenwoman

Be a real superhero this pregnancy by delivering one of the most essential elements, oxygen, to your growing and developing baby. Although it can feel taboo to take a medication during pregnancy, if you are feeling breathless, it is likely that your baby is also not getting enough oxygen. Remember, the benefits of treating asthma during pregnancy generally outweigh the potential risks of the medication. So, talk to your doctor, stay away from irritants (like smoke, dust, pollen etc.), and take control of that breath! And when you see your big and healthy baby take his or her first real breath, you can finally let your breath be taken away!

 

Nadia Mohamedi is a teratogen information specialist and also serves as a research assistant/interviewer for OTIS studies in San Diego, CA. She holds a BA in neurobiology and a minor in psychology from Harvard College. In addition to her work with OTIS, Nadia has worked for the Alcohol and Drug Abuse Treatment Program at McLean Hospital as well as served as a teacher’s assistant at a school for children with disabilities in Lima, Peru.

OTIS is a North American non-profit dedicated to providing accurate evidence-based information about exposures during pregnancy and lactation. Questions or concerns about medications and other exposures during pregnancy or breastfeeding can be directed to OTIS counselors at (866) 626-OTIS (6847) or online at OTISPregnancy.org.