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Antidepressants and Pregnancy: 5 Most Important Questions Answered by the Psychiatrist

You might be taking antidepressants when you get pregnant, or you might be prescribed antidepressants to treat an issue you've developed during pregnancy. No matter what the scenario is, antidepressants should be taken seriously. To help you get through this topic, we've prepared a series of interviews with Professor of Psychological Medicine, Kathryn M. Abel.

Professor, let's start with the numbers. Do many pregnant women suffer from depression?

It's a really interesting question because it seems like it should be simple to answer. But, actually, you get very different figures for how many pregnant women suffer from depression depending on where you look and how you look. The information from wealthy populations in the West suggests that between 5 and 10 percent or 1 in 20 to 1 in 10 mothers is depressed in pregnancy. This may be higher in poorer communities or in other countries. 

And how often do healthcare providers prescribe antidepressants to pregnant women?

That’s another really important question. Two very good studies report that, in recent generations, many more mothers are getting depressed.

What we are sure about is that, since 2005, significantly more young women and girls from the age of 15 are being treated with antidepressants. In the UK population of young women, now between 10 and 20 percent are taking antidepressants; and many of these young women will also be becoming pregnant.

It isn’t completely clear if all the increase is because more women are actually getting depressed or because it’s so much more common for people to talk about things like depression so more women are coming forward to be treated and are then ‘seen’ in the data. 

But, what we are sure about is that, since 2005, significantly more young women and girls from the age of 15 are being treated with antidepressants. In the UK population of young women, now between 10 and 20 percent are taking antidepressants; and many of these young women will also be becoming pregnant. 

Most women don't know that they are pregnant for at least 6 or maybe 12 weeks i.e. until they have missed at least 2 periods. So, some women will be getting pregnant when they are on antidepressants. 

What we also know in the UK data is that if you have a diagnosis of depression during pregnancy you are 12 times more likely to be treated with an antidepressant than a woman who does not have a mental illness diagnosis. 

If you have a mental illness diagnosis that isn’t necessarily depression, you are still about 8 times more likely to be treated with an antidepressant.

So, what we can say is that currently lots of women are being treated with antidepressants during pregnancy. 

In the UK at least, GPs in primary care are not likely to start women on an antidepressant during pregnancy without referring them for specialist help. But, very large numbers of women may be on an antidepressant at some time during pregnancy even if many of them stop once they know they are pregnant. 

It's very hard to know the numbers of women who only start an antidepressant during pregnancy because the information available is not very accurate.

Can you name some factors taken into consideration when the decision about antidepressants is made?

The really important thing about this decision is to be able to have a conversation with the person recommending starting or continuing antidepressants, particularly because, as you have seen, the information is quite complicated.

The most important thing is that any decision is collaborative. In other words, it's a decision making process which occurs between the treating clinician and the woman, and her family. And one of the most important things, very simply, is how ill she becomes when she is not on medication, or how severe her depression is.  

The really important thing about this decision is to be able to have a conversation with the person recommending starting or continuing antidepressants.

If she has relatively mild to moderate depression, then there are many things that could help her. She can have talking therapies, other forms of psychological support, fresh air, exercise, a good diet, etcetera etcetera. All of these things are good.

A pregnant woman’s general health is very important. She needs to make sure that she's resting, has plenty of sleep; if she has other children, that she has help, that she is supported, that she exercises regularly, avoids alcohol or other drugs and eats well. It is important she attends her antenatal clinical care and takes her folate supplements. 

These sound very much like what we may hear in any sensible advice column; in a woman's magazine; they're just sensible, preventive public health measures about general health and general mental health and mood.

These days there are very good Internet digital supports, for example reading Flo-blogs, getting support through Flo-chat rooms from other women, or from trusted family and friends, making contact, not getting isolated. 

All of these apparently simple elements are really important.

And if it's a woman’s first pregnancy, booking early into antenatal clinics will mean she gets lots of helpful information from the nursing staff because most antenatal services are really good and understand the difficulties women face and the risks of poor mental health.

In my view, prenatal care is one of the best aspects of healthcare worldwide. In some settings, wise women such as doulas or grandmothers, mothers, in the community can provide information that's really helpful. So women can get a lot of support in an informal way, which means they don't have to take medicine. 

Another decision that women can make with their doctor is whether or not they withdraw from a medicine once they know they're pregnant. If you've been on an antidepressant before pregnancy, and you've been on that antidepressant for over six months - a year, two years depending, and if you've been well, then there is every reason for you to come off it gradually. And the likelihood is your mood will remain stable. 

Can you say if the prescription of medication/antidepressants depends on the term of pregnancy?

That's a good question.

Of course, the answer depends on what you are most keen to achieve with medication. If a woman is unwell enough to need an antidepressant, she should be treated at whatever stage of pregnancy she is in.

If she is well and stable on medication and would like to withdraw to become pregnant, avoiding exposure in the first 12 weeks of pregnancy, which is the critical time for the developing brain, may be preferable.

If there are concerns about postnatal withdrawal in the infant, then avoiding antidepressants in the last 12 weeks would be advisable. However, overall, a decision should be made on the basis of the woman’s clinical need because there really isn't the information available to answer this question with any degree of certainty with respect to how these medicine affect the infant.

If we remember that most women are likely to have mild illness and we cannot ethically randomise women to receive antidepressant or a placebo as that is not considered ethical. 

My view is that the lack of good quality information makes it very difficult for mothers, and the clinicians supporting them. They want to do the best, and one thing we can say is that pregnancy is safer and healthier than it has ever been - for women and for their infants.

We are involved in a big piece of European work which hopes to look at a range of different stressors in very early life on the embryo and producing effects in infants and children. So maybe in 5 or 10 years’ time, you can ask me again and I will have the information!

We do know that if a mother is starved or experiences a major bereavement or other adversity that the growth of the fetus or its development can be compromised.

And it certainly looks like the first 12 weeks of pregnancy, or the first trimester, is a more period sensitive. That’s probably because so much of development is happening then in crucial areas of the central nervous system and brain. In boys, from about 16 weeks of pregnancy, the testes start to produce testosterone and this may be a particularly important period for male fetuses. However, there is little research to guide us on sex differences. 

My view is that the lack of good quality information makes it very difficult for mothers, and the clinicians supporting them. They want to do the best, and one thing we can say is that pregnancy is safer and healthier than it has ever been - for women and for their infants. 

Things that we now do globally include routine antenatal care, giving folate to mothers in the first trimester routinely and checking the growth of babies using ultrasound and clinical examination throughout pregnancy. The midwives check your baby and ask you a lot of questions; importantly they take your blood pressure, test urine for sugar and check your kidneys. There are so many ways in which we keep babies and mothers healthy today.

So, it’s very difficult to know what causes the particular increase in problems that we see in mothers with mental illness and their infants: whether it is medicines taken in the first trimester, at a time of particular sensitivity for development; or whether they are just very high-risk moms to begin with so that it wouldn’t matter if they had taken an antidepressant in the first trimester, second, or third trimester. 

We do know that infection in the first trimester has a greater effect on fetal growth and prematurity than, say, an infection later in pregnancy. But if you have an infection like malaria, for example, in the second or third trimester, you may lose your baby. So, all of pregnancy is a time of risk but, for development, the beginning of pregnancy ie the first trimester is the most sensitive period. 

Thank you. And is it safe to stop taking antidepressants abruptly when pregnancy occurs?

It is safe in as much as it is unlikely to be fatal to stop taking antidepressants abruptly.

But, if you think about taking antidepressants and stopping them abruptly when you are not pregnant, what we know is that you are likely to suffer with unpleasant withdrawal symptoms, particularly with SSRIs. This can make people agitated, anxious and have difficulty sleeping.

So these same withdrawal phenomena would be likely to occur if a woman were to stop abruptly when she discovers she is pregnant. In pregnancy your blood volume increases by around 20 percent, so the amount of drug is diluted. So pregnancy reduces the concentration of antidepressant in the blood. If mothers wish to stop they should stop very gradually: over 2 to 3 weeks, in the same way, you would, if you were not pregnant.  

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