New Recommendations For Depression During Pregnancy, But Few AnswersS

Two medical associations recently released a report advocating that decisions on depression treatment for pregnant women be made on a case-by-case basis. For many expectant moms, this isn't much help.

According to Roni Caryn Rabin of the Times, the report, published by members of the American Psychiatric Association and the American College of Obstetricians and Gynecologists, recommended that doctors try talk therapy first if a woman's depression is mild or moderate. But it also said that the risks of antidepressant use and shock therapy on the developing fetus are low. Dr. Kimberly Yonkers, the lead author of the report, says,

There's not a one-size-fits-all answer. You can't say, ‘Stop medication for all women because it's harmful,' and you can't put all women on medication either.

Most pregnant women can probably agree that there is not a one-size-fits-all answer to their depression (for proof, check out the Times commenter who says she cured her PPD by drying and eating the placenta). But beyond that, the report may not give them much guidance. The authors still caution that because of the lack of randomized clinical trials on pregnant women, research on drug side effect is limited. And four of the report's nine authors had some connection to drug companies, casting all their drug recommendations into a certain amount of doubt.

Paxil, Celexa, and Zoloftall seem to increase the risk that a baby will be born with a hole in the heart. The holes often close on their own, and the risk of the defect is less than 1%, but it increases if the mother took more than one SSRI. SSRIs can also raise the risk of persistent pulmonary hypertension, a condition that impedes blood flow to the baby's lungs, but the risk of this is also low, about 1.2%. Perhaps the greatest risk is that of drug withdrawal, experienced by 15 to 30% of babies born to moms who took SSRIs late in pregnancy. This can cause irritability, hypoglycemia, and even seizures in babies, but usually gets better within two weeks. Untreated depression, of course, has its own risks. In addition to the dangers to the mother, it may contribute to premature birth, growth changes, or irritability in babies.

Not all clinicians even agree with the report's relatively mild recommendations. Dr. Shari Lusskin says,

By the time I get to hear about somebody's perinatal depression, it's usually worse than what can be treated with psychotherapy alone, because women go out of their way not to complain; they don't want to be put on medication, and they feel guilty. We should use a low threshold for treating women aggressively.

And though the report emphasizes the relatively small risk of drug side effects, many women aren't reassured. One commenter on the Times Well Blog, who suffers from bipolar disorder, wrote,

I've been stable for a long time, but going off all my medication might change that. A high-risk perinatal physician recommended that I stay on everything, because depression and manic psychosis may be harmful to the baby. But my psychiatrist recommended ceasing all medication for at least the first trimester, which is the phase where the developing embryo is most sensitive to mutagens. Her recommendation is that I should go off everything and then, if I have a problem, I should use electroshock therapy. I have decided that this is the right path to take. But I'm still putting it off.

Rabin interviews Sherean Malekzadeh Allen, who says, "Every single thing you put in your body when you're pregnant, you wonder, ‘Oh, my God, am I growing my baby an extra finger?' I was worried that I would hurt the baby if I took the pills, and I was worried I would hurt the baby if I didn't." She was so anxious about hurting her baby with her medication that, "I would wait six or seven hours before taking the pill, and just work myself up into more of a state." Ultimately, her son was born healthy.

Given the low risk of serious birth defects from antidepressants, Allen's story — in which the biggest side effect is maternal guilt — is probably the most common. The APA/ACOG report may have its problems, but at least it doesn't issue any blanket pronouncement that might add to this guilt. It may not be a very useful guideline, but it's true that depression, whether during pregnancy or not, should be evaluated on a case-by-case basis, and that what works for some sufferers won't always help others. For those pregnant women who respond well to talk therapy, the choice seems clear. But those who need medication have to balance the risks to their babies with the benefits of having a happy, healthy mother. Like so many aspects of parenting, this balance is individual, and the report deserves praise for acknowledging that.

Image via New York Times.

Depression Is A Dilemma For Women In Pregnancy [NYT]
Coping With Depression During Pregnancy [NYT Well Blog]