In the absence of randomized studies of fetal and newborn exposure to antidepressant medications, clinicians are left with the dilemma of balancing the risks of medications to the fetus and newborn against the risks of not treating or undertreating the mother.
Behavioral Interventions As Alternatives to Antidepressants
Surprisingly, researchers agree about individualized evaluation and treatment for pregnant women with depression and recommend alternatives to medication, including cognitive-behavioral therapy, interpersonal psychotherapy, behavioral activation, mindfulness-based cognitive therapy, and acceptance and commitment therapy. Where they differ significantly is where to place the emphasis in the patient-physician discussion.
Byatt’s group advocates for emphasizing the mother’s illness. “Clinicians are often understandably concerned about exposure to medicine, and we certainly want to minimize exposure to medicine as much as possible,” she says. “However, depression itself can have an effect on birth outcomes, baby’s health, and later on child health. That must be taken into account because discontinuation of antidepressants may increase the risk of relapse into depression, which carries its own risk.”
“I recommend that providers strongly consider the risk of untreated illness and relapse into depression when making decisions regarding the use of antidepressants during pregnancy.”
Urato strongly disagrees with that approach. “The issue here is that if it’s true that depression leads to pregnancy complications and that the antidepressants safely and effectively treat depression, then it clearly follows that when we do studies we should be seeing better outcomes in births of depressed women treated with antidepressants compared to those not treated,” he says.
“But that is never what the studies shows,” Urato adds. “In over 25 years of study, the groups of women on the antidepressants consistently do worse. They have more miscarriages, more birth defects, more preterm births, and their children do worse, so there is something wrong with that helpful drug model.”
Instead, he advocates changing the discussion more temporally and prioritizing nondrug approaches to treating depression long before women become pregnant. By the time women get to their obstetricians, it is too late to have this discussion because many women don’t come to their doctors until after the baby’s organs have formed, and already have had six to 12 weeks of exposure, Urato notes. It can be very difficult to come off these drugs during pregnancy.
“Depressed pregnant women need good treatment and care. Any discussion of whether these medications are safe or not should not be seen as an argument to ignore depressed pregnant women,” Urato says.
“As a society, however, nonmedical therapies should be first and foremost with women of child-bearing age who are seeing a doctor about symptoms of depression” he continues. “We need to have a discussion about nonmedical as well as medical treatments long before [women] become pregnant.”
Michael O’Leary is a freelance medical writer based in the greater Seattle Area. This article was medically reviewed by Pat F. Bass III, MD, MS, MPH.
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