Studies released over the last year have raised a spectrum of concerns regarding the use of antidepressants during pregnancy, whereas others have brought into focus the risk for new onset or relapse of depression during pregnancy and the impact of maternal depression during pregnancy on obstetrical outcome and neonatal well-being. These findings received a considerable amount of attention in the literature and in the media.
Among the concerns raised was the extent to which fetal exposure to one selective serotonin reuptake inhibitor (SSRI)—paroxetine—has been associated with an increased risk for cardiovascular malformations. In other studies, SSRI use during pregnancy was associated with compromised neonatal adaptation with symptoms of jitteriness, tachypnea, and tremulousness, which is known as “neonatal abstinence syndrome.”
This finding of transient neonatal jitteriness and tremulousness has been highly consistent across studies dating back to the mid-1970s, when similar concerns were raised with prenatal exposure to the older tricyclics. About 25% of children who are born to mothers treated with SSRIs, particularly late in pregnancy, appear to have these symptoms.
It is noteworthy, however, that the clinical relevance of the syndrome seems small. Even in the most rigorous study to date, which described a subgroup of children exposed in utero to SSRIs, those who had these symptoms required no particular treatment interventions during the acute neonatal period. (OB. GYN. NEWS, April 15, 2006, p. 12).
Also reported last year was our collaborative study with investigators at the University of California, Los Angeles, and Emory University, Atlanta, demonstrating that the rate of depressive relapse associated with antidepressant discontinuation during pregnancy is high—about 70%—compared with 25% among pregnant women who maintained treatment with these medicines across pregnancy.
These new data on teratogenicity, treatment-emergent neonatal syndromes, and relapse risk have provided more well-delineated information on the risks and benefits of antidepressant use during pregnancy.
The information is extremely important in this setting, because antidepressant use during pregnancy in the United States may be as high as 4%–6%, based on estimates by some of our recent work.
A study published last summer by investigators from the University of Michigan, Ann Arbor, illustrates the fact that while depression is relatively common during pregnancy, most women at risk for illness don't receive any treatment, and, when treatment is prescribed, it is often suboptimal.
In the study, 1,837 pregnant women from five hospital-affiliated obstetrics clinics were screened for depression, 276 of whom were identified as being at risk. Only 20% of the at-risk women were receiving some form of antidepressant treatment. Of the group getting treatment, 48% received a combination of medication and counseling with psychotherapy, 21% received antidepressants only, and 31% received psychotherapy only. Still, in many cases, treatment was inadequate. Only 43% of those taking antidepressants for 6–8 weeks were given the recommended daily dose.
Among the women who met the criteria for major depressive disorder, only 33% received any type of treatment; only 11% received what was reported to be adequate antidepressant therapy (Gen. Hosp. Psychiatry 2006;28:289–95). The low rate of treatment of depression during pregnancy may reflect concerns regarding the effects of antidepressants on the fetus. However, even women in the study who received psychotherapy alone did not receive an adequate intensity of treatment.
One has to wonder whether these findings reflect concerns over the past year about fetal exposure to antidepressants. It is notable that, even when a clinical decision is made to use antidepressant therapy, treatment is incomplete.
Incomplete treatment of depression during pregnancy represents a failure in clinical risk-benefit decision, because the woman and child are exposed to both medication and the adverse effects of the disorder. And clinical depression that is untreated during pregnancy is the strongest predictor of postpartum depression—which can have enduring effects for the patient, her newborn, and her family.
The Michigan study underscores the need for effective strategies to detect and treat women at risk for depression during pregnancy. Sustaining euthymia and maintaining emotional well-being during this period should be our major clinical goals.