Recently, another research study (in the prestigious British Medical Journal) linked antidepressant use during pregnancy to an increased risk of psychiatric disorders in the exposed children. Much controversy surrounds this topic — and a great deal of misinformation. Two issues, in particular, seem to be “missed” in the public discourse.
The first misconception is the notion that depression during pregnancy should not be treated because treatment may entail risks. Let’s be clear from the outset — depression is a horrible and deadly condition for many and should be treated in pregnancy. Depression is truly awful for the suffering it causes. It can have effects not just for the pregnant woman but also the family, community, and baby. In the worst-case scenario, depression can lead to suicide. Rates of suicide have increased significantly in the past decade with depression implicated in the vast majority of cases. The CDC data shows that suicide is a leading cause of death in childbearing-age women. The completed suicide rate scratches the surface of the problem. It is estimated that there are 10 to 40 nonfatal attempts for every completed suicide. Even for those who don’t consider suicide, the suffering from the depression itself is horrible.
The problem with depression and pregnancy is not that the mom needs to suck it up and forgo treatment, but rather that depression is a potentially fatal condition that is becoming more widespread. It needs to be recognized as such and, as a society, we need to have better approaches to prevention and treatment. Treatment can involve psychotherapy, exercise, and antidepressants. In some of the public discourse, pregnant women choosing antidepressants are portrayed as making a selfish or whimsical lifestyle decision. This isn’t accurate. Depression can be a life or death matter for some, and the decision to take medication is a challenging and often agonizing one. The idea that such women should not have children or receive compassionate care is unfair and unhelpful. The take-home point from this should be clear — depression during pregnancy should be treated.
The second misconception is the notion that antidepressants might somehow not have effects on the developing baby or pregnancy. Antidepressants are synthetic chemical compounds that enter the fetus throughout development — so, of course, they can have consequences for a baby’s development. The question isn’t whether these chemicals have effects but rather how they affect the baby. Given the discussion above, it would be wonderful if we had antidepressants that didn’t enter the baby or cause fetal effects. But that notion is absurd. Years of scientific study in animals and humans clearly shows that antidepressants do go 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/language problems, childhood epilepsy, and other difficulties (e.g., delayed motor development.) Newborn MRI studies show that SSRI-exposed babies have changes in brain structure, white matter microstructure and cerebral metabolism. And it’s not just the brain — the drugs enter all the organs and are likely to have widespread effects. Studies consistently show these drugs to be associated with preterm birth, birth defects, newborn behavioral syndrome and maternal postpartum hemorrhage. Furthermore, we have no idea what the long-term effects might be for children and adults exposed in-utero.
The public is often confused by scientific studies that do not show that antidepressants are associated with some complication or another (e.g., autism). The press often reports the results as showing that the drugs are “safe in pregnancy.” What the public doesn’t realize is that studies will often not declare an association between, for example, antidepressants and autism, unless there is statistical significance (e.g., a p-value < 0.05). This is often a difficult bar to achieve in human research. Many studies do, in fact, find an association, but without statistical significance. Reporters or the authors themselves then conclude that there is no risk. Then, a few months later, a study might be published reporting statistically significant harms, 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, the SSRI antidepressants have been used in pregnancy since the late 1980s, but only now, decades later, are MRI studies being done — and they are all showing effects in the brains of exposed babies. So, make no mistake about it, synthetic chemical compounds entering 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.
Unfortunately, public discourse suggests only two possible approaches: 1) rRspect depression, care about depressed 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’s a better approach. That approach (and what depressed pregnant women and the public need) is compassionate care and accurate information recognizing the severe consequences of depression while making it clear that chemicals going into a baby throughout its development will likely have consequences for that development. There is no “one size fits all” approach to this issue and patients need information on the risks, benefits, and alternatives for all therapies for depression including medication, psychotherapy, exercise, and other options. This approach can actually work in practice. Physicians can show compassion and care for pregnant women suffering from depression, counsel them appropriately. And then, support them 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 these misconceptions are corrected and that pregnant women and the public get proper information and care.
Adam C. Urato is a maternal-fetal medicine physician.
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