This month another study came out showing that children who were exposed to antidepressants in utero have higher rates of anxious/depressed behaviors in childhood. This follows a separate research study (in the prestigious British Medical Journal) that came out last fall, linking antidepressant use during pregnancy to an increased risk of psychiatric disorders in the exposed children. And just this week the fifth MRI study was published showing that antidepressant exposure in utero affects fetal brain development.
There is much controversy surrounding this topic and a great deal of misinformation. Two issues, in particular, seem to be getting “missed” in much of the public discourse.
1. Worry about antidepressants does not mean “no treatment” for pregnant women
The first misconception is the notion that depression during pregnancy should not be treated because treatment may entail risks to the fetus. Let me make it clear from the outset: depression is a horrible and potentially deadly condition and it should be treated in pregnancy.
For some, treatment can involve medication use. However, it can also be treated with psychotherapy, exercise, family/group support, and other non-drug approaches.
Depression is truly awful for the suffering it causes the pregnant woman. Such suffering can have effects not just for the woman, but also the family, the community, and the baby. In the worst-case scenario depression can lead to suicide. Rates of suicide have increased significantly in the past decade — and depression is implicated in the vast majority of these cases.
Even for those who do not consider suicide, the suffering caused by the depression itself is horrible. The problem with depression and pregnancy is not that the mom needs to have a stronger will, “suck it up,” and forgo treatment, but rather that depression is a serious condition that is becoming more common among pregnant women.
This is a maternal health and a public health problem that needs to be recognized. The research on the risks to the fetus from the use of antidepressants suggests that we need to have alternative approaches for preventing this condition from developing in pregnant women and treating it if it does occur.
As noted above, treatment of depression can involve, among other things, psychotherapy, exercise, and antidepressants. In some of the discourse on this topic, pregnant women who choose to take antidepressants are portrayed as making a selfish or whimsical lifestyle decision. This isn’t fair or accurate. The decision to take a drug during pregnancy is a challenging and often agonizing one. Any argument that women who suffer from this condition should not have children or receive compassionate care is unfair and unhelpful.
In sum, the take-home point should be clear — depression is a serious condition and depression in pregnant women needs to be treated. The question is how best to do that.
2. Research has shown that antidepressant use poses a real risk to the fetus
The second area of misunderstanding is the notion that antidepressants might somehow not have any effects on the developing baby or the pregnancy. Antidepressants are synthetic chemical compounds, manufactured in chemical factories, that pass into the fetal bloodstream and enter the amniotic fluid and developing fetal organs throughout the pregnancy. As a result, an antidepressant of course can have consequences for a baby’s development.
The question isn’t whether these chemicals affect the developing baby but rather how they affect the baby. Given the discussion above (under point #1), it would be nice if we had antidepressant drugs for pregnant women that didn’t cross the placenta or cause any fetal effects. But that notion is illogical. After years of study in animals and humans the scientific evidence clearly shows that antidepressants do enter into the developing baby throughout the pregnancy and are associated with pregnancy complications and fetal effects.
This just makes sense. It’s implausible (absurd actually) to believe that drugs that enter the adult brain and cause significant changes in that organ won’t also cause effects when they enter the developing fetal brain.
Antidepressant exposure in pregnancy has been linked to autism, ADHD, speech and language problems, childhood epilepsy, adolescent depression, and other difficulties (e.g. delayed motor development). Newborn brain MRI studies show that SSRI-exposed babies have changes in their brain structure, white matter microstructure, brain connectivity, and cerebral metabolism.
And it’s not just the baby’s brain that can be affected. The drugs enter into all of the baby’s developing organs and are likely to have widespread effects. Studies consistently show these drugs to be associated with, for example, increased rates of preterm birth, birth defects, newborn behavioral syndrome, and postpartum hemorrhage in the moms. Furthermore, we have no idea what the long-term effects might be for the children and adults who were exposed in utero.
The public is often confused by scientific studies that do not show the antidepressants to be associated with some complication (e.g. autism) or another (e.g. preterm birth). The press often reports the results as showing that the drugs are “safe in pregnancy.” What the public doesn’t realize is that scientific studies will often not declare an association between, for example, antidepressants and autism or preterm birth, unless there is a statistically significant finding (e.g. a p value < 0.05).
This is often a difficult bar to achieve in human research studies. Many of these studies do, in fact, find an association, but without a statistically significant p value. Reporters or the authors then conclude that there is no risk with antidepressant use. Then, a few months later, a different study might be published reporting statistically significant harms associated with the drug’s use, the drug is declared unsafe, and the public is totally confused.
What’s happening is that harmful effects of drugs on developing babies can take years to demonstrate consistently with statistical significance. For example, SSRI antidepressants have been used in pregnancy since the late 1980s, but it is only now, decades later, that MRI studies are being done and they are all showing effects in the brains of the babies who were exposed (here and here and here and here and here). So, make no mistake about it, synthetic chemical compounds going into the brains and bodies of developing babies do affect development — they must. And when it comes to chemical exposures in pregnancy, the “arc of history” consistently bends toward showing increasing harm over time.
Reconciling points one and two
At first glance, the two abovementioned points — 1. that depression during pregnancy should be treated and 2. that chemical exposure poses risks to fetal development — seem to create a real conundrum. Yet there is a straightforward solution: prioritize non-drug approaches to treating depression in pregnant women.
Non-drug approaches to depression — such as CBT, mindfulness, exercise, light therapy — have been shown to work as well as antidepressants in numerous studies. Furthermore, initial use of an antidepressant may lead to long-term use, and, in general, long-term outcomes with antidepressants are poor. Longer-term studies regularly show better outcomes for the unmedicated patients.
This approach validates the importance of treating these women while attempting to minimize fetal exposure to synthetic chemical compounds during development. Furthermore, given that most patients find it difficult to stop taking these medications, the argument can be extended to say that we should prioritize non-drug approaches to treating depression in women of childbearing age.
What to do then with the pregnant woman who is appropriately counseled regarding the risks, benefits and alternatives to antidepressants and still wishes to take them during pregnancy? That answer is simple: Support her and give her the best care possible during her pregnancy.
Unfortunately, the public discourse on this topic suggests that there are only two approaches: 1) respect depression, care about depressed pregnant women and tell them the drugs are safe and won’t affect the developing baby, or 2) protect developing babies, tell pregnant women not to be treated, and make them feel guilty if they take antidepressants.
Fortunately, there is a better approach. That approach (and what depressed pregnant women and the public need on this issue) is compassionate care and accurate information that recognizes the potentially severe consequences of depression while making it clear that chemicals going into a baby throughout its development will likely have consequences for that development. Non-drug approaches can be prioritized in order to safely and effectively treat depression without ongoing fetal chemical exposure.
There is no “one size fits all” approach to this issue and patients need information on the risks and benefits for all therapies for depression, including medication, psychotherapy, exercise and other options. This approach can actually work in practice. Health care providers can show compassion and care for pregnant women suffering from depression, counsel them regarding the risks and benefits of various treatment options, discuss alternatives, and support them with whatever they choose to do — depression during pregnancy need not go untreated. With rates of depression increasing and rates of antidepressant exposure growing, it’s imperative that the above misconceptions are corrected and that pregnant women and the public get the proper information and care.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.