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Antidepressants During Pregnancy: Is It Safe?

Kathryn Abel, Professor of Psychological Medicine, speaks on the safety of antidepressants during pregnancy.

Is it safe to take antidepressants during pregnancy?

It depends what you mean by safe. So, for example, is it safe for the mother? Yes, it's safe for the mother, and it may be more safe for the mother to take an antidepressant if she is very depressed or actively suicidal; or if she has a history of recurrent depression. It may be more safe to continue to take antidepressants than to stop because it may prevent her from relapsing into a further depressive episode. 

It is important to remember that many, if not most of the mothers in a population of women who have a diagnosis of depression have a mild form of depression. If you have a mild form of depression, it is much more likely that it gets better on its own without medical intervention or drugs. Help and support from your friends, or your family, or maybe some talking therapy usually works without the need for medication.

More intensive psychological support like cognitive behavioural therapy or CBT is usually only needed for more severe depression which is a moderately bad form of the illness. Mild depression often resolves on its own with time. 

In our population of more severe women who stay depressed, we think about 5 percent of them continue to take antidepressants during pregnancy. That is an average figure; but in pregnant women on antidepressants, it ranges between about 2 or 3 percent 20 years ago and 10 percent of pregnant women today. What this means is that at this time at least in the UK between 1992 and 2017  ie over the past 25 years, more depression is being reported and more antidepressants are being prescribed.

That's important because, of course, in 1992 we didn't have SSRIs and people were very concerned about treating women with tricyclics - the old antidepressants. Today, most women will receive SSRIs. 

Is it common for women to take antidepressants in the postpartum?

If we look at what happens in the first year after birth, about double the number of mothers are taking antidepressants compared to during pregnancy.

This information comes from primary care, from GPs. That's important because, if we look at Swedish data which only includes secondary care and probably women with more serious illness, the rates are much lower. Women with depression that is bad enough are referred to a psychiatrist; if they are even more unwell, they're referred to inpatient care.

The numbers of women in Sweden with more severe depression during pregnancy or after birth are much lower; as are the numbers receiving antidepressants.

This suggests that most probably between 70 to 80 percent of the women with depression in the UK primary care setting have a much less severe depression and may be quite a lot of them could and should be treated without medication because they have a milder form of illness.

Do antidepressants in pregnancy affect baby?

If we think about whether it's safe for the baby to be exposed to a mother’s antidepressant, well, the answer is quite complicated.

It’s complicated because the information we have about possible effects of antidepressants on the fetus are confused by the severity of a mother’s illness.

In other words, the more severe a depressive illness, the more likely the mother will be given an antidepressant. But also the more likely she will smoke, eat poorly, miss antenatal appointments, forget to take folate supplements, or be deprived and unsupported. 

So, independent of whether a mother is taking a particular medicine, the fetus is exposed to many other adverse factors that can influence its development and chances of doing well. Most of the information we have about what happens to children if the mother is taking antidepressants relates to women accessing secondary care where women tend to be more severely depressed and so she may not look after herself or do all the things that make you healthy as a mom when you're pregnant. 

In other words, for all pregnant women who are depressed, lots of things about how you behave as a woman who's depressed, not the antidepressants themselves, not even the depression, make your baby more likely to have problems.

We see that mothers ill enough to be in secondary care who are depressed, whether they take antidepressants or not, are more likely to have premature babies, slightly smaller babies, babies with a little more difficulty at birth. There is also evidence of a relationship between depression in pregnancy and risk of autism in children, particularly autism without intellectual disability; i.e. more high functioning autism. More girls, maybe, in that group than boys. Autism with intellectual disability is more likely in boys.

It's unlikely just to be about SSRIs, however, because before SSRIs, we also see a risk of autism in the offspring of mothers who have depression. 

And there's a final layer of complication to this story about depression in pregnancy, antidepressants in pregnancy and the risks for infants. 

First, we know that SSRIs are not just given for depression but, increasingly, are prescribed for a range of problems including obsessive–compulsive disorder (OCD), anxiety, panic, poor sleep, psychosis, schizophrenia, bipolar disorder - many different things are treated with SSRIs. 

Secondly, compared to women who are pregnant at the same time but don't have mental illness, or to women with any mental illness during pregnancy, depressed pregnant women appear to be much more likely to receive many other medicines apart from antidepressants.

For instance, they are nearly 3 times more likely to receive antibiotics during pregnancy. Women taking antibiotics during pregnancy usually means that they've had an infection and the commonest cause of prematurity and poor fetal growth (small babies), is infections in pregnancy. 

You can see, now, how complicated this question becomes when we say that treating a depressed woman is associated with having small premature infants! This may have nothing to do either with antidepressants or with having depression. 

If women want to know about safety of antidepressants in relation to infant/fetal congenital malformations, the story may be a little more straightforward. WHO reports that about 3 percent of all pregnancies develop congenital malformations. Most malformations are minor and treatable such as cleft lip, or anomalies of fingers etc, rather than major heart defects. The rate is about 3-4 in 100 births so it's low in the general population. 

If a woman needs to take antidepressants during pregnancy, the sense is that these medicines are safe for infants

We know that some of the risk factors associated with depression or other mental illnesses are the same as those for congenital malformations. So young or teenage mothers are more likely to have babies with congenital malformations as are mothers in poverty. But when you look at the rates in excess of women who are depressed in pregnancy and taking antidepressants, about one more child in a hundred is developing congenital malformations. And again, most of those are likely to be minor - not major heart defects, as such. 

So in general, if a woman needs to take antidepressants during pregnancy, the sense is that these medicines are safe for infants.

Some medicines clearly have been linked to problems, however. Paroxetine has been associated with specific congenital heart defects and pulmonary hypertension (it’s high blood pressure in the lungs of babies).

Other antidepressants have been linked with bleeding disorders in pregnancy and poor fetal growth while many infants may show temporary irritability after birth which is thought to be a type of SSRI withdrawal syndrome because at birth the baby no longer shares a circulation with the mother and no longer receives any SSRI– this doesn’t usually require treatment, however.

Do you have more questions about antidepressants and pregnancy? Don't miss this nterview: Kathryn Abel answers 5 top questions. 

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