Antidepressants, Pregnancy, and Autism: Why Wouldn’t Antidepressant Chemicals Affect a Developing Baby’s Brain?

Adam Urato, MD
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This week another study was published (Boukhris, 2015) showing that SSRI antidepressant use during pregnancy is associated with increased rates of autism in the children.  By my count, this is now the tenth study on this topic and it follows on the heels of previous studies by Croen, Eriksson, Rai, Harrington, Gidaya, El Marroun and others – all of which found links between SSRI antidepressant use in pregnancy and autism in the offspring.  Most of these studies were recently reviewed by Man, et al, who also concluded that SSRI antidepressant use during pregnancy is associated with autism in the children.

So we now have numerous studies in different human populations all showing a link between SSRI use in pregnancy and autism in the children.  Yet, much of the news and blogosphere focus on casting doubts about these findings.  What is going on here?

Depressed Pregnant Women Should Not Be Ignored

I am deeply concerned about the effects that the SSRI chemicals have on the developing fetal brain.  But, let me start by making it perfectly clear that my concerns about the effects that SSRIs have on the developing fetal brain are in no way a call to ignore depression in pregnant women or to tell them what to do.  I counsel pregnant women every day in the hospital where I was born and in the community I grew up in.  Many of them stay on their antidepressants.  Some of them wean off.  My experience has taught me a few things.

First off, depressed pregnant women need good treatment and care.  This treatment can be with non-drug approaches such as psychotherapy or exercise or with medications.  But, whatever treatment approach they choose, depressed pregnant women should NOT be ignored.  Secondly, I don’t think anyone should be telling pregnant women what to do.  The key is to provide them with the best available information that the scientific studies are showing and let them decide what is best for themselves.  They should then be supported in their decision and continue to be given excellent care.  Knowledge is power and we need to empower women in this area.

Currently, Pregnant Women and the Public Aren’t Getting Full Information

A major issue that seems to be missing from the public debate on this topic is the fact that the substances that we call “antidepressants” are, in fact, synthetic chemical compounds that are manufactured in chemical facilities and they have a chemical effect in the brain.  This is important to recognize, because chemicals have consequences for developing babies.  Yet, if you read most of the news coverage on this topic, you very rarely (if ever) see a discussion about toxic chemical effects.  (The word “chemical” usually doesn’t appear in these news stories).  When I read this news I wonder:  “Where is the discussion of what effects these antidepressant chemicals are having on the developing brain?”  Let me explain:

  1. Serotonin is a naturally occurring substance that plays a crucial role in the development of a baby’s brain.
  2. The SSRI antidepressants are manufactured chemicals that disrupt the serotonin system.

If you (the reader) just think for a moment about points #1 and #2, you can quickly see that there may be big problems with the use of these chemical agents in pregnancy.  If serotonin is crucial for the development of the baby’s brain and the SSRIs disrupt that system then it is a recipe for problems.  (The only way it wouldn’t be a problem would be if the antidepressant chemicals did not cross the placenta.  But we know that they do freely cross over into the baby’s developing brain.)

So if we just think about this issue on a theoretical basis, there is major cause for concern.  The basic science is clear that serotonin plays a crucial role in the developing fetal brain and that these manufactured chemical compounds disrupt the serotonin system.  But the science goes beyond just theoretical considerations.

Animal Studies are Showing Harm

There have now been numerous animal studies done in this area and the findings from these studies are very concerning.  Again and again we see that when animals are exposed to SSRI antidepressants during development that they show brain and behavioral problems (or so-called neurobehavioral problems.)  There are too many animal studies now that have shown this to review them all in detail, but a few stand out.  In 2004, Mark Ansorge and his group published a landmark paper in the journal Science (one of the leading scientific journals in the world.)  This paper showed that mice that were exposed to Prozac during development had altered emotional behaviors.  In the conclusion of that paper (more than 10 years ago!) Ansorge warned:  “The use of SSRI medications in pregnant mothers and young children may pose unsuspected risks of emotional disorders later in life.”  In 2011, Kimberly Simpson and her group studied the effects of Celexa on rats and they also found concerning changes in the brains and behaviors of the exposed offspring.  They warned:  “our findings are consistent with the possibility that dysregulation/dysfunction of the 5-HT [serotonin] system during early brain development may be the critical contributing factor in the etiology of ASD [autism spectrum disorder].”

These are just two papers, but there are many more animal studies showing that SSRI exposure can alter the developing brain and lead to neurobehavioral problems.  And I want to be clear here.  These animal findings make sense because chemicals that affect the brain (so called psychotropic chemicals) would be expected to have consequences for a developing brain.  So if you expose a developing brain to a synthetic chemical you would expect to have some effect from that and that is precisely what the animal studies show us.

Human Studies are Showing Harm

So what the scientific research is showing us makes sense.  Serotonin is a molecule that is crucial for a baby’s brain development.  The SSRIs disrupt the serotonin system.  The animal studies show brain abnormalities and neurobehavioral problems.  So when we do human studies in this area we would expect to see brain abnormalities and neurobehavioral problems.  And that is, in fact, what we do see.  Study after study in humans shows that the exposed babies have brain abnormalities including Chiari I malformations and smaller head size and neurobehavioral problems including autism, ADHD, motor problems, and anxiety.

What the Public Isn’t Getting: Human Studies Always Have Some Flaws

What I find so astounding/frustrating in this area is that when the human studies show effects on the developing baby’s brain—like autism (effects that we would expect from the basic science and animal studies), reporters and editorialists immediately rush to cast doubt on the human studies.  They highlight the limitations of doing large epidemiologic studies and how many problems these studies might have.

It is true that studying something like the link between antidepressants and autism in human populations is very challenging.  There are lots of confounding factors, caveats, and limitations.  There is no “gold standard” randomized-controlled trial available because most researchers don’t think it would be ethical.  But, at the end of the day, the human studies are confirming what basic science, animal studies, and common sense would tell us:  putting brain-altering synthetic chemicals into a developing baby’s brain can alter development.  The simple question for those who doubt the basic science, animal data, and human research is:  “What do you think happens to the baby’s brain when it’s exposed to these chemicals throughout its development?”  Why wouldn’t there be an effect on the baby’s developing brain?

Conclusion

Depressed pregnant women need good treatment and care and I counsel patients in my community on this issue every day.  There is no “one size fits all” or “right” answer for every patient.  But what my patients (and the public) need here is the correct information so that they can make informed choices.  The best available scientific evidence shows:

  1. That serotonin is crucial for a baby’s brain formation
  2. That the SSRI antidepressants disrupt the serotonin system
  3. That the drugs freely cross the placenta, and (4) that animal studies show brain effects in exposed offspring.

When a human study comes out showing brain effects (autism) from exposure to these drugs (point #5 of my argument), then we should use this as an opportunity to inform the public rather than cast doubts on the findings of human studies and further confuse the issue.

There are non-drug approaches to depression that have been shown to work for many women, including psychotherapy and exercise.  And, given what we know about the effects of these drugs, it makes sense to prioritize these non-drug approaches in pregnant women and women of childbearing age.  However, some women will opt for antidepressants; that’s their choice and they should be fully supported and given good care.  This is not about telling women how to manage their depression.  The key here is informing patients and the public so that they can make the best decisions for themselves.  And the information that the public needs to hear is that the best available scientific research suggests that the antidepressant chemicals do enter the baby’s brain and do affect its development.  After all what do we think will happen when we expose developing brains to brain-altering chemicals?

* * * * *

Take Adam Urato’s online course, offered on Mad in America Continuing Education:

Antidepressants & Pregnancy: The risks and possible harm to normal fetal development and the newborn child 

The course, which is free for viewing and offers CEU and CME credit for a small fee, is a review of the unbiased research on risks vs. benefits of prescribing antidepressant medications to pregnant women 

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28 COMMENTS

  1. Dr. Urato, are you aware of studies that have compared the risks of staying on ADs vs the risks of withdrawal in pregnancy? Please correct me if I am mistaken but my impression is that the animal studies were comparing drug exposed to never exposed, which is not helpful in answering this question. I do know of a study that showed discontinuation was linked to re emergence of depressive symptoms (likely withdrawal related, though they phrase it as relapse) – see http://www.ncbi.nlm.nih.gov/pubmed/16449615. And what is your actual experience with how pregnant women who may already be having pregnancy related mood problems and physical issues like morning sickness handle withdrawal? Some people have terrible experiences with it and I can’t image that not harming a fetus too.

    I raised these issues in a different discussion, and am curious what your thoughts are. Seems to me that the discussion should be more around preconception health and dangers of prescribing to women of childbearing age, since even if a woman who becomes pregnant on ADS can successfully wean off, she will still have some exposure (and that exposure would be in the time that is most important for birth defect risk)

  2. I don’t think the practice of prescribing SSRI antidepressants to women in pregnancy would be so prevalent if it weren’t for the postpartum depression diagnosis. There’s that, and the fact that women in general are more apt to be diagnosed depressive and to be compliant patients besides. If you doubt it, look at the stats. I certainly feel that doctors should refrain from prescribing any drug stronger than aspirin, if that, to a pregnant women. There is not only the risk of autism, but there is also a risk of birth defects, and while the percentages may be small, putting babies at risk is never a good idea. In other words, not drugging fetuses is a no-brainer, and doctors should be pointing out that it is a no-brainer to prospective parents. I’d say the doctor who didn’t do so should be made culpable on top of it. Nothing is so preventative as the example of successful malpractice suits.

  3. Thank you Dr. Urato for explaining the risks of SSRIs on developing fetuses in clear language. You recommend exercise and counselling which is excellent. Another very important condition for maternal and baby’s health is diet. Jill Littrell mentions the crucial importance of Omega-3s. Doctors often seem to overlook the importance of telling their patients, including those who are pregnant or trying to get pregnant, what a good diet should include. Many young women are on very questionable diets these days and I fear for the next generation of babies to be born. Please keep informing your patients of the importance of diet for both preventing depression and having a healthy baby.

  4. “What is going on here?” It seems likely that since the psycho / pharmacutical industries, and their media payees, have spent the past several decades lying to the public, claiming antidepressants cure a seratonin system “chemical imbalance in the brain.” Rather than truthfully, as you did, claiming “antidepressants disrupt the seratonin system.” Telling the truth now is likely embarrassing for all of them.

    Thank you for truthfully warning pregnant women of the harms of the antidepressants, and I do so hope the medical community, as a whole, stops passing these poisons out like candies, to little girls and young women.

  5. I wonder why few are exploring the possibility that the following might be going on: depressed mothers (who more frequently take antidepressants) are probably worse mothers in terms of being less effective at providing love, care, and support to developing babies both pre and post birth (no, they’re not bad people… these mothers probably had worse parenting themselves). The main causal factor in these studies could be worse mothering resulting in a greater chance of withdrawal / faulty brain development in the child leading to functioning on the autistic spectrum. The antidepressants themselves could have little to do with a greater chance of autism – or they might; it’s not clear at this point.

    Contrary to popular opinion, this possibility of poor parenting influencing likelihood of autism has never been disproven: We still do not have a clear biological etiology for autism, nor is autism clearly separable from other conditions at its less severe edges. Given this uncertainty, the fact remains that it’s a possibility that poor mothers and fathers may increase the risk of developing autism spectrum conditions. This would actually be a more hopeful formulation, because parenting can be changed and improved, sparing some children from developing autistic behaviors who otherwise would have.

    It would be interesting to see studies looking at the correlation between abuse, neglect (in parents and children) and diagnosis of autism. I bet a link would be found there too.

    Yes, I have worked with and known autistic people, and I still feel this way.

    • BPD,

      Why it is to hard for you to accept that there are neurological variations in human beings that have nothing to do with poor parenting? And by the way, would you be able to prove that all the people you know with autism were the victims of poor parenting?

      • AA, I don’t deny that… yes, there are neurological variations in human beings that arise from genetic inheritance and from the incredibly complex and varied way that genes/brain interact with the nonhuman environment, which may not relate to parents much if at all for a given individual.

        As for your question, of course not… but can you prove that neurological variations not influenced by social relationships cause autism in people you met? I don’t think so.

        Why is it so hard for you to accept that poor parenting might contribute to or even cause autistic spectrum behaviors? If correct, that would be a hopeful or meaningful way of understanding things, in my opinion.

        I think at this point we don’t know that much about autism or its causes, if it is even one unitary thing… and it’s both a real possibility that poor parents are contributing to autism risk, and that natural neurological variation is contributing to what we call “autism”… or some combination of these factors that’s different in each case.

        • I would also question what natural neurological variation is… this is a loaded term. It implies some element of randomness/chaos, and also has a note of determinism, i.e. the possibility that genes sometimes “go wrong” and cause autism. I think the state of our knowledge in these areas is quite primitive.

          An interesting book on these topics is Evelyn Fox Keller, The Mirage of a Space Between Nature and Nurture. In her thinking, nature and nurture are not separable, and genes (nature) would not exist or do anything without the environment (nurture). So in a sense neurological variation is not completely “random”, although it is incredibly complex and can appear random. Rather, in each individual case, genes interact with the environment (parents, other creatures, and other nonhuman elements) in an interpenetrating way where genes guide development and the environment actively modifies genes. It’s hard to get one’s mind around this complexity. Brian Koehler’s recent article on epigenetics was a good introduction. It makes sense to me that given how dependent genes and environment are on each other, that human relational influences are probably more important to the development of behavioral problems (including autism) than is often thought by people who see genes and environment as separate quantifiable influences.

          • Hi BPD, You get my vote on subtlety in appropriate context on the final “genes gone off wronging us” analysis. I don’t want to push the envelope beyond that point myself: as your remark suggests, what the DNA is, is something complete and exists as given in and for the individual, but this person is not its genetic impress. And they have to tell us more than the biologist and lab tech., who are simply materialists in the life sciences vein, such specialists as will want to say we must require nothing exceptional of each other in listening skills or be labelled abnormal at birth. In order to account for their personal viewpoints and the states of their rational minds, however, people have to get tolerated and encouraged and enticed by the chance to restate their purposes and explore their limitations to surpass their physical potentials. It’s obvious that the biological view isn’t cuttie-cutter simply a matter of top-down reductions.
            The nature and condition of anyone’s real understanding can’t stop at the door that the specialist says requires them to file through for their managed care. The human sciences and neurosciences compete for obsolescence in pharmaceutical research as it is, and as AA tends to reveal, they incline toward decadence and nanny state defeatism their many indiscrete, blithesome followers. You really field the questions and the ambiguities of the human condition with authority, these days…so have you heard of Dennis Noble’s work at countering “The Selfish Gene” with his “The Music of Life”? The tide is turning, there, in some note for revival of Sheridan’s work, and academics are tackling his dualism to examine what limits his discernments–specifically, in regard to what is and is not “presenting” of objective or subjective behaviors. The web presence is convenient since the Buddhist and Science series of Oxford kicked off the lectures promoting the book.

          • Hi travailler-vous, I have not heard of these books no. Books I’ve read on genes / epigenetics include those by Matt Ridley (The Agile Gene), Jay Joseph (The Gene Illusion), Evelyn Fox Keller (Mirage of a Space Between Nature and Nurture). A few others that I cannot remember. Most of these were years ago and I am not so well read on this area. I would like to do more reading on epigenetics. I know Brian Koehler, who recently had an article on MIA, is coming out with a new book soon on epigenetics and looking forward to that.

            I also really like Richard Lewontin’s book – Not In Our Genes – which was one of the earliest counterattacks against the notion that mental illnesses/problems are determined by genes. I recommend you to check that out.

            I will go and look up the names you cited online.

  6. Pregnancy is a huge psychological and physiological stress on a woman’s body and on a family. It is 100% NORMAL for anxiety, depression, anger, and all sorts of emotions to emerge during this time, and yet we do little to nothing to prepare new moms for this experience. We’d be FAR better off normalizing pregnancy as a natural period of adjustment and depression as an indicator that some thing or things need to be changed in the mom and family going forward.

    Other stressors include the potential loss of income, loss of role at work, changes in sex life (which can lead to frustration by her partner), body image problems, expectations from partners and/or extended family members, planning for childbirth (including paying for it in some cases), loss of sleep, big changes in schedule, increasing isolation after the birth, the list goes on and on and on.

    There is also a huge increase in the incidence of domestic abuse during pregnancy that is almost never discussed in the context of PPD or maternal/prenatal depression. The shift of attention from a self-centered partner to the developing baby often triggers jealousy in such partners. Additionally, pregnancy often provides a sense that the mother is now under more control of the abuser, and abuse can escalate without fear of her leaving.

    Add to that the tendency for pregnancy to bring up childhood abuse/neglect issues, and it seems very understandable that depression increases during pregnancy and childbirth. How someone can view depression during pregnancy as a disease state is beyond me. I’m surprised that anyone isn’t filled with anxiety and dread at the idea of starting a family in this culture and economy! Antidepressants should be the very last choice of desperation by any doctor, as there are so many other things that can be done. And the very process of diagnosing and prescribing for this “condition” kind of automatically invalidates the long and yet non-exhaustive list of legitimate reasons to be worried or dismayed that I have provided above. It is beyond idiocy to diagnose a pregnant woman with “prepartum” or “postpartum depression” when it is such a normal part of a very stressful process and doing so I think does a lot of damage to our chances of ever really finding out how to help.

    — Steve

  7. My wild ass guess tells me that poor and working class women are over-represented among those who are prescribed ADs during pregnancy. My best guess tells me that there’s less tolerance for “weirdness” the lower on the social status scale you go, so their offspring are more likely to be diagnosed and drugged for any number of reasons, “autism” included.

  8. Taking chemicals during pregnancy should be a last resort. Multiple studies associate the use of anti-emetics, anti-depressants and other medications for other concerns with autism and other fetal damage. Suggesting that autism could instead be related to parenting or other factors is denying the obvious and is both misguided and very damaging and unfair for these parents as they work to help their children overcome the obstacles posed by neurological damage. These chemicals very likely damage developing fetuses and are rarely worth the risk.

    • If you feel that taking chemicals during pregnancy should be a last resort, would you mind informing my local Community Mental Healthcare facility then. I have been involved in the CMH setting for 35 years and I’m not the Dr. or the therapist. I was the patient and our psychiatrists urge patients to stay on their ‘cocktail’ (5 or more) drugs during pregnancy, not come off of them. Never in all those decades have I heard one psychiatrist encourage a patient to eliminate any of her drugs. And it may be due to putting the Mother into severe withdrawals which could be fatal. But then psychiatry doesn’t believe that we endure emotional and mental torture during withdrawals. We are not believed at any point.

      • I am not a doctor. I hear you and am sorry that things sound so difficult. I realize that if someone is on prescribed medications when they become pregnant that coming off the medications also presents a difficult process, so there are no easy answers. Having a doctor you trust, doing your own research and using as many alternatives to meds is my best understanding of what can help. Best Wishes…we all should be respected and believed.

  9. Other toxins as well have been correlated with the development of autism. I share these in response to my concern that some here are still suggesting that inadequate parenting causes autism.

    http://www.hsph.harvard.edu/news/press-releases/fine-particulate-air-pollution-linked-with-increased-autism-risk/

    I fully agree that parenting and attachment issues are related to many mental health conditions including some of the emotional problems of children born with autism. However, to suggest that the developmental delays and extreme difficulties associated with a diagnosis of autism are caused by bad parenting is damaging and not backed by research.

    • Well, I wanna address your “concern that some here are still suggesting that inadequate parenting causes autism”…. I’m assuming you’re referring to a comment / thread begun by “BPDTransformation, B.A.”, above. I believe you, “Truth….”,
      are both mis-quoting, and mis-characterizing the comments.
      I hear “BPD” ASK A QUESTION about possible parenting influences on later “diagnoses” of “autism”, – so-called “ASD” / “autism spectrum disorder”…..
      Yes, “semantics” has reared its’ ugly head….*THINK*….
      We don’t know very much at all about “ASD”, either root cause, or actual etiology….
      You, “Truth….”, would do well to focus MORE on the ever-lamer DENIALS, and the lies of the pseudo-science LIE known as “psychiatry”, and the marketing LIES of Pharma….
      At least your derisive snorts are politely phrased….
      (c)2015, Tom Clancy, Jr.,

    • “Truth”–Since diagnosis isn’t the same as the cure of disease or distress, then establishing better models for parenting has to come very high on the list of research interests and various trials of clinical method, right? So there has to be some good and bad parenting styles or approaches determined, with good and bad potentials recognized across the populations, case by case. Getting better with your kid has some plain everyday meaning, and doctors aren’t the heroes or the heavies unless they refuse to stand in and take over carte blanche for the parental authority. And they are no doctor at all if they see parents looking for the ultimate out in biology, and then fail to suggest better guardianship than by those who want all the answers coming from biological research for their autistic offspring.

      • I am in complete agreement with you that better parenting of all children should be high on any research agenda. I just don’t know of any research that shows that what we call autism is caused by (problematic) parenting. However, I agree that the label of autism may be imprecise or invalid and include more than one condition. My understanding is that what is meant by the label autism is something that probably includes neurological differences and damage. Given the skyrocketing use of medications during pregnancy and increasing environmental toxins and the growing number of studies that support these toxins as a cause of neurological harm to fetuses, we cannot ignore these results.

        I agree that no matter who a child is biologically, better parenting can only help. We are both biology and experience, not just one or the other. Do you have experience parenting a child with a diagnosis of autism? As someone who has long valued (and still does) looking at the environment (including parenting) as a possible cause for emotional suffering, I have found it quite humbling.

        • Truth in Psychiatry–Hi, thanks for the acknowlegments in reply to my thoughts. In case you wondered about the quotes, I just got curious about abbreviation “rules” and counldn’t think better than that right then.

          To answer your question, no I don’t face that contingency as parent or legal guardian. As uncle married into a family, I had to quell my favorite sister-in-law about her rowdy, unruly toddler (my nephew Aaron) who was a tremendously proficient biter. He got served according to the daycare’s helmet law, and Leilee was surprised that he let it take no fun out of his social opportunities there. But that’s not as difficult as dealing with toddlers whose coping strategy is severely deficient, and whose real problems are not merely developmental and adaptive ones. I am very sorry for your plight, and always believe that your voice counts here in your favor as a Mom just how it truly must count to you.

          • Thank you for your response. I also value your perspective and share your concern that children can easily be blamed for problems that originate with parents, our educational system or our society. We must do better all the way around!

  10. As an actually autistic person, I feel really offended and frustrated that Mad In America has publisehd at least two ableist pieces recently that invoke fear of autism to hype fear of psychiatric drugs – which we have plenty of reason to be concerned about anyway.

    There is a perfectly obvious and reasonable explanation for why children born to mothers taking SSRIs might be more likely to be diagnosed as autistic, which is that people with neurodivergant traits themselves are more likely to suffer in ways that are labeled as “depression” and be prescribed SSRIs than the general population.

    Regardless of the actual source of these children’s autistic traits, treating being born autistic like some kind of injury to be avoided is ableist and extremely harmful to autistic people, who suffer a tremendous amount of systemic abuse in our society already without the additional fear-mongering from gross, speculative, unscientific anti-psych and anti-vaccine imaginings. I hope MIA will reconsider telling these kinds of stories in the future.

    • Yes! You should speak up and tell your own story. I haven’t heard from many autistic people about how they view the autistic label and how they want to be viewed. It seems like you have a few articles on MIA about other topics but not ones that specifically relate to autism and your own story. MIA can provide a good platform for this.

    • I am guessing from knowing the people who run the site that they would be happy to give me the opportunity, though I’m not super clear it’s worth my while or that I will find energy for that.

      It does take a lot of energy to speak up in a space that is actively marginalizing you, which in my understanding is why the writing community on this site remains disproportionately white, male, wealthy, cisgender, heterosexual, and normatively-abled.

      Mad In America is centered one particular kind of oppression we all have faced but is not a very intersectional space. It perpetuates a lot of other kinds of oppression in its structure.

      I think the leadership really ought to really be doing a lot more to create a welcoming environment for folx whose experiences are particularly vulnerable and not being centered.