Depressed pregnant women need good care. They should not be made to feel guilty for the choices they make concerning their depression or lectured to by those who don’t understand the area or lack compassion for them. In that sense, Andrew Solomon does the public a service by turning his attention and writing talents to the topic of depression and pregnancy this week in the New York Times. However, a crucial part of providing good care to depressed pregnant women is to give them accurate information on the topic. In this sense, Andrew Solomon falls short, as his article misses the mark in several important areas. I will address these point by point:
1. Chemicals Have Consequences for Developing Babies
I have been lecturing and writing on this topic for the past decade and one of things that stands out most to me is that there is some public misunderstanding about the fact that the agents that we call “antidepressants” are actually synthetic chemical compounds that are made in large chemical factories. When pregnant moms take these drugs, these chemical compounds are going into the baby’s organs and affecting essential processes all throughout the baby and for the entire pregnancy. This “toxic chemical” aspect of the subject seems strangely to be missed in much of the public discourse on the topic. The key question is: “What exactly happens when these foreign chemicals are entering into the baby throughout development?” This is a crucial question for the public and this is the question that we (eg the public, medical science) need answered. It seems absurd for us to think that there is no effect to the baby from exposure to these synthetic chemical compounds.
I have communicated with Andrew Solomon by phone and email on this topic and I encouraged him to help advance the public discourse on this topic by using his article to talk about the “chemical” aspects of this problem— What exactly does happen when these chemicals are entering into the baby throughout development? While I don’t think it’s appropriate to quote my communications with him directly, I do feel comfortable saying that he gave me the impression that he wanted to get into this “chemical” area in this current essay but that the “chemical toxicity” aspect is considered too technical for New York Times readers. I think this is tragic, because this is a major aspect of this topic. An essay on depression during pregnancy and antidepressant use that does not explore the chemical toxicity aspects is very limited.
To elaborate on the topic of chemical toxicity, I want to focus for a moment on male sperm formation (a little odd for a specialist in Maternal-Fetal Medicine, like myself, but please bear with me). Several recent studies have shown that males who take SSRI antidepressants will have reduced sperm concentration, more sperm with DNA fragmentation, and more abnormal sperm. (Again, it appears to be a toxic chemical effect.) This has now been shown in several studies and it is not an effect of the males being depressed or anything like that (we know this because we see these toxic sperm effects in healthy males who are given the drugs as an experiment or in males who are taking the medications for premature ejaculation—not for depression.)
Most scientists who study this area recognize that these toxic effects of the SSRIs on the development of male sperm make sense. After all, SSRI antidepressants are synthetic chemical compounds and it likely that they would have a “chemical” effect. So why would such chemicals (the SSRI antidepressants) that have toxic effects on developing sperm not have toxic effects on a developing baby?
We know that serotonin is a neurotransmitter and cell-signaling molecule that is absolutely crucial for a baby’s development. We know that antidepressants (ie SSRIs) freely cross the placenta, enter into the baby, and disrupt this serotonin system. However, discussion of this area of chemical effects or toxicity was almost completely missing from the article.
2. No one Wants a Pregnant Woman to Kill herself. (Anecdotes have Limitations)
An article in which pregnant women stop their medications and kill themselves while others continue on their meds and have happy outcomes is sure to push readers in an obvious direction. However, such anecdotes are limited. For example, the author could have told stories of women who stayed on their medications, weren’t counseled regarding the risks, and had severely impaired babies. Or women who stayed on their medications and increased the doses and then committed suicide. Anecdotes can be powerful stories and emotionally push readers in one direction or another. But for every anecdote supporting one viewpoint, there is another one to support some other viewpoint. That is why we need to be scientific and ask what exactly these chemicals are doing for the moms and the babies. For example, the scientific research does not support many of Andrew Solomon’s anecdotes. In the actual studies, the women who stay on their medications are more likely to have pregnancy complications (eg preterm birth, preeclampsia, and newborn complications) than the depressed women who do not take medications. If the anecdotes reflected the science there would have been more anecdotes about women on the medications who had children with heart defects, preterm birth, seizures, and autism.
Let’s be clear that if a woman is suicidal when she stops her medication, then it certainly sounds like she needs to keep taking her medication. A dead mother is no help to herself or her baby. But many of the women whom I counsel and many of the women on these medications do not consider themselves to be in that category. Finally, we need to keep in mind, that issues regarding antidepressant use and suicide are complex. It should not be forgotten that the SSRI antidepressants have been found to increase suicidality in young people who take them. That is why the FDA placed a black box warning on them in 2007 and it’s what was found in a 2009 review published in the British Medical Journal. As far as I can tell from the research studies, the best available evidence shows increased rates of suicide with the use of antidepressants by young women and not a protective effect.
3. Many Excellent Studies in Well-respected Journals are Showing Harm
At one point in the article he writes: “Many have heard that SSRIs can be terribly harmful from online message boards, from news reports influenced by an individual doctor, or from small studies that have been amplified into universal statistics.” This suggests to the reader that the scientific evidence of harm is weak (online messages, an individual doctor, small studies) but this is just not the case. In the list below I am going to hyperlink to numerous human studies that are found in the world’s leading medical journals showing the evidence of harm. But I want you to understand that I could hyperlink to dozens and dozens and dozens more human and animal studies that show harm when we expose developing babies to these chemicals: Human studies show that SSRI use during pregnancy is associated with miscarriage (Canadian Medical Association Journal), birth defects (British Medical Journal), preterm birth (PLOS One), preeclampsia (British Journal of Clinical Pharmacology), decreased fetal head size (Archives of General Psychiatry), newborn behavioral syndrome (Archives of Pediatrics and Adolescent Medicine), seizures (American Journal of Obstetrics and Gynecology), neonatal EKG changes (Pediatrics—the official journal of the American Academy of Pediatrics), childhood brain malformations (Neuropsychopharmacology), and long-term neurobehavioral issues like ADHD (Molecular Psychiatry) and autism (Pediatrics—the official journal of the American Academy of Pediatrics.)
4. The Antidepressant-treated Group Never has Improved Pregnancy Outcomes in the Scientific Studies
The model that the public has been sold on this topic by the key opinion leaders in reproductive psychiatry (many of whom have been paid by the antidepressant makers themselves) is as follows (I refer to it as the “helpful antidepressant model”):
A) Depression during pregnancy leads to pregnancy complications (eg preterm birth, preeclampsia, and newborn complications.)
B) Antidepressants are safe and effective at treating depression.
Andrew Solomon’s essay appears to embrace this model. But if a) and b) are true, then the research studies should show that the antidepressant-treated group has improved pregnancy outcomes (ie fewer pregnancy complications.) But this is never the case. What the studies show, again and again (dozens and dozens of them), are worse pregnancy outcomes in the medication group (that is, the group that is chemically exposed.) The medication group has more birth defects, preterm birth, preeclampsia, newborn complications, etc.
Many defenders of antidepressants like to use insulin and diabetes as a supporting example for the “helpful antidepressant model.” (“You wouldn’t ever tell a pregnant diabetic not to take insulin would you?” they argue.). But this example actually works against their argument. I take care of pregnant diabetics on a daily basis and I can tell you both from first-hand experience and from what the scientific research studies show that proper treatment of diabetes with insulin leads to better pregnancy outcomes—and it is not hard to show this. The treated diabetics do better with their pregnancy outcomes—they have fewer birth defects, less preeclampsia, etc. The fact that we keep seeing the exact opposite with antidepressant use during pregnancy shows that the “helpful antidepressant model” above is broken. And it’s broken either because points a) and/or b) above are not true, or that any benefit of the antidepressants is overwhelmed by their toxic chemical effects on the pregnancy.
5. What about Autism?
Rates of autism have been increasing dramatically and the public wants to know what things may be contributing to this. Exposure to SSRI antidepressants in utero have been linked to autism in the offspring. It struck me as somewhat remarkable that the word “autism” doesn’t appear even once in Andrew Solomon’s article.
It is now clear from the scientific research that serotonin plays a key role in brain formation. The antidepressant chemicals alter that serotonin system, so we should expect these chemical compounds to impact the developing brain. Animal studies show increased rates of autistic-like behaviors in exposed offspring. Several human studies have also shown this. The most comprehensive review of this research was just published. I will quote the conclusion of the study: “The findings of this meta-analysis and narrative review support an increased risk of ASD [autism spectrum disorder] in children of mothers exposed to SSRIs during pregnancy.”
If a patient in my office asks me, “Doctor, is there any scientific evidence that using these drugs during pregnancy might lead to autism in my child?” What should I tell her? How does Andrew Solomon suggest that we answer this very important patient question?
6. The Power of the Drug Industry
A major “player” that is missing from Andrew Solomon’s story is the antidepressant industry (Big Pharma as some call it.) I don’t think you can tell the story of antidepressant use in pregnancy without reference to this industry and he basically doesn’t touch on this—aside from mentioning my concerns.
Some facts are clear. Women of childbearing age are major users of antidepressants. The drug industry knows this and women of childbearing age have been targeted by drug-industry marketing for decades. However, one big “obstacle,” from a drug-industry standpoint, to women taking these medications is the “problem” of pregnancy. Pregnancy could be a reason for a woman to never start up on an antidepressant (“what if I can’t stop when I want to get pregnant?”) or it could be a reason for a woman to stop taking her antidepressant (“what effects do these chemicals have on my developing baby?”) She may stop and never resume taking the drug.
It seems clear to me that from a drug company sales standpoint, the best case scenario is to downplay risks and have women of childbearing age view these drugs as basically being safe in pregnancy.
I don’t think it’s just a coincidence that throughout the past three decades, as society has been trying to figure out if these medications are safe for use in pregnancy, that the leading centers of reproductive psychiatry and the key opinion leaders have been paid large sums of money by the antidepressant makers. (This has been reviewed in detail here, here, and here.) Why were the drug companies pouring so much money into the pockets of the reproductive psychiatrists? Did that money influence the conclusions of those groups that these medications are basically safe in pregnancy?
Andrew Solomon emphasizes scientific doubt and uncertainty in his article, but he doesn’t mention how the antidepressant industry funds much of the science in this area and how industry uses “sowing doubt” in the public mind as a technique to confuse the public about chemical harms in order to keep selling their product. This is, like, the oldest trick in the book (from cigarettes to asbestos to benzene.) The antidepressant industry has been pouring millions of dollars into academic medicine over the past decades and for many in the public there seems to be a lot of doubt about whether antidepressants (synthetic chemical compounds that enter into all of the baby’s organs and alter essential physiology) harm the fetus. Does anyone believe that it is a coincidence? What would the science actually look like if it weren’t exposed to (or corrupted by) industry dollars?
7. No One Should be Telling Pregnant Moms What to Do
Depression during pregnancy can be a tremendous challenge for women, their families, and their medical providers. I take care of patients with depression during pregnancy on a daily basis and I can tell you, first hand, that it is heart wrenching and that I strongly believe that these women need excellent treatment and care. Part of that excellent treatment, I think, is getting these patients correct information so that they can make the best decisions about how to handle their depression.
Some argue that the “correct” information that pregnant women need is that these chemical compounds are safe for moms and developing babies. I disagree with that. I think that these chemical compounds come out of the chemical factories, go into the pregnant moms, and cross over freely into the developing babies. I think they enter into all of the baby’s organs and act with a toxic effect, disrupting crucial processes that have been a part of fetal development for millions of years. I think that these “antidepressant” chemical compounds cause injury to these babies.
But, while I strongly believe that the drugs cause harm, I don’t believe that a pregnant woman should be told that she should take a medication or that she should not take a medication. That is an individual choice and one that should be respected. What I do think such women need is an honest discussion about what the best available scientific evidence suggests are the risks, benefits, and alternatives to the various approaches. The woman should then decide what’s best for her (in consultation with her family, mental health providers, other medical providers, and others whom she chooses.) She should be supported in her decision (whatever it may be) and given the best care possible throughout her pregnancy and beyond. That is how I care for my patients every day.