Women taking antidepressants to manage chronic depression face a difficult decision when they become pregnant: Should they stay on the medications to keep from relapsing into depression, or should they stop taking the drugs to avoid potential harm to the developing fetus?
Local researchers contend the evidence suggests that women with past episodes of mild to moderate depression skip popularly prescribed antidepressants — selective serotonin reuptake inhibitors, including Prozac, Paxil, and Celexa.
In a review of more than 100 studies published last Wednesday in the journal Human Reproduction, researchers from Boston IVF and Tufts University School of Medicine took the controversial position that "there is no evidence of improved pregnancy outcomes with antidepressant use" while there are established downsides, such as an increased risk of miscarriage, preterm birth, and behavioral problems in newborns.
"We're not talking about those with severe depression," who may need to stay on the drugs to prevent suicidal tendencies or a relapse that could leave them unable to get out of bed, said study coauthor Alice Domar, a psychologist who heads the Domar Center at Boston IVF. "But those who have had milder episodes need to be warned of the risks in order to make an informed decision."
Many doctors don't broach these risks with their patients because the conventional medical wisdom has been that unborn babies are better off being exposed to antidepressants than the elevated stress hormones and other physiological effects of a mother's untreated depression.
But experts agree that research studies to date haven't established a connection between depression and poor pregnancy outcomes. Research does, though, suggest that use of some antidepressants raises the risk of miscarriage from about 8 percent in the general population to 12 percent to 16 percent in those who use the drugs during pregnancy.
"The complication rates with the use of these drugs aren't low," said study coauthor Dr. Adam Urato, chair of obstetrics-gynecology at MetroWest Medical Center in Framingham, who also serves on the faculty at Tufts University School of Medicine. But, researchers can't get a precise measurement of the increased risks because the pregnant women in the studies who choose to stay on those antidepressants tend to have more severe depression or other complicating health issues.
Whether antidepressants have any long-term mental health effects on children exposed in utero remains an unanswered question. Nearly a third of newborns born to mothers who took selective serotonin reuptake inhibitors develop a condition called "newborn behavioral syndrome" that causes jitteriness, feeding problems, and inconsolable crying during the first few days or weeks after birth. In some cases, babies develop severe breathing difficulties and require a breathing tube.
"Newborn behavioral syndrome is very rare in babies who aren't exposed to these drugs," said Urato; it usually resolves on its own after a short period of time.
Some psychiatrists, however, have criticized the study authors for downplaying the benefits of antidepressants and magnifying the risks.
Certain women with severe depression will likely experience a relapse if they go off their medications. "For them, antidepressant use isn't optional," said Yonkers, "just like diabetics or epileptics can't stop taking their medications during pregnancy. This isn't a one size fits all deal."
The American College of Obstetricians and Gynecologists and American Psychiatric Association issued a joint statement three years ago advising women taking antidepressants who have had mild or no symptoms of depression for at least six months to consider tapering off the medications before they become pregnant but added that "medication discontinuation may not be appropriate in women with a history of severe, recurrent depression."
Domar said she doesn't dispute these recommendations but added that the majority of patients who are taking antidepressants in her infertility clinic have mild to moderate depression. (A recent review of electronic medical records at Boston IVF revealed that 11 percent of infertility patients were taking antidepressants.)
These patients could get just as much benefit from cognitive behavioral therapy or relaxation techniques such as yoga, Domar added, without the risks posed by the drugs.