Depression, Antidepressants, and Pregnancy

Making the best choice for you and your baby

When Jennifer B. became pregnant with her first child, she faced a difficult decision. The 45-year-old physical therapist had been taking antidepressants for five years to treat depression. She was concerned that taking medication during pregnancy could harm her developing baby, but she had also seen what can happen if you stop.

Jennifer's younger sister had gone off antidepressants (on the advice of her obstetrician) during her pregnancy just one year earlier. And Jennifer watched in horror as her sister spiraled downward into severe depression. "She was nearly at the point of hospitalization when she changed doctors, got back on antidepressants, and started to stabilize," says Jennifer. So when Jennifer became pregnant a year later, she was determined to experience pregnancy differently.

"I had many conversations with my OB and psychiatrist, and I weighed the pros and cons of continuing my medication," says Jennifer. "The risks of not taking medication through pregnancy – both for me and my baby – seemed to far outweigh the risks of continuing to treat my depression with medication, so I had to go with what would make me the healthiest mother I could be."

Depression and pregnancy
It's a choice many women face. According to a 2009 study by the American Congress of Obstetricians and Gynecologists and the American Psychiatric Association, up to 23 percent of pregnant women experience depression. At least 13 percent take antidepressant medication during pregnancy. But others decide not to treat their depression or choose alternatives to medication.

"Sometimes a woman will come into my office and tell me she's willing to suffer for nine months because she doesn't want to take medication that might harm her baby," says Healy G. Smith, MD, a Manhattan reproductive psychiatrist who specializes in treating women before, during, and after pregnancy.

But according to Smith, untreated depression can also have a severe impact on the health of a mother, her pregnancy, and her fetus – as well as her child's later development. "Parenting unquestionably involves sacrifice," says Smith, "but it's essential to acknowledge the importance of maternal well-being for a child."

Your treatment options
There are benefits and drawbacks both to using medication and to going without it, says Olivia Bergeron, a New York-based licensed clinical social worker who specializes in treating women with perinatal depression. "Educating yourself about your options is essential. The gold standard for treatment is psychotherapy combined with medication. However, some people will respond very well to just therapy or just medication. I usually do not advocate medication alone." 

Common forms of therapy for pregnant and postpartum women include cognitive behavioral therapy, interpersonal therapy, and supportive or psychodynamic psychotherapy.

But if the mood disorder is intense enough to affect a woman's basic ability to function, her quality of life, and her feelings about her developing baby, it is a sign that she may have a more serious depression or anxiety disorder that might be better managed with a combination of medications and therapy according to Stephanie Ho, MD, a reproductive psychiatrist in private practice in New York City and a clinical assistant professor of psychiatry at NYU Langone Medical Center.

How antidepressants work
Your brain is a well-run communication system that uses chemical messengers called neurotransmitters to send messages between neurons. Those messages include information about emotions, body temperature, appetite, or behavior and are delivered by synapses.

Once a neurotransmitter has delivered its message, it returns home to be reabsorbed by the neuron it came from (a process called reuptake), and that simple act is where mood disorders enter the story. Two of these chemical messengers are serotonin and norepinephrine, and low levels of them in the synapses are connected to depression and sadness.

The most commonly prescribed antidepressants in pregnancy and the postpartum period are selective serotonin reuptake inhibitors (SSRIs), such as Prozac, Zoloft, Lexapro, and Paxil. They work by slowing or blocking the reuptake of neurotransmitters, such as serotonin, so more of the chemical remains in the synapses where it helps to regulate mood and relieve depression.

Other classes of antidepressants frequently prescribed during pregnancy are serotonin-norepinephrine reuptake inhibitors (SNRIs), such as Effexor and Cymbalta, which inhibit the reuptake of two transmitters critical to mood – serotonin and norepinephrine.

Tricyclic antidepressants, such as amitriptyline and nortriptyline, also block the serotonin and norepinephrine transporters, keeping more of the feel-good chemicals circulating. These drugs are prescribed less frequently because SSRIs and SNRIs are considered so safe and effective.

Weighing the risks of medication against the risks of untreated depression
Unfortunately, there is little information about what effect medications may have on a pregnant mother or a fetus because almost no adequate tests have been done. However, many women take antidepressants during pregnancy on the advice of their doctor.

Of the 500,000 pregnant women who struggle with a mood or other kind of psychiatric disorder, about one-third of them will take medication to treat it, according to the American Congress of Obstetricians and Gynecologists. From their medical records, doctors are able to make educated decisions about the safety and efficacy of antidepressant use during pregnancy. 

"SSRIs have been available for 25 years, and there is an overwhelming body of literature showing that they do not cause birth defects," says Samantha Meltzer-Brody, associate professor and director of the Perinatal Psychiatry Program at the University of North Carolina Center for Women's Mood Disorders. "SSRIs have a strong safety record. Also, they have been scrutinized more than any other medication that a pregnant woman would take due to the stigma of mental health issues."

Of course, all medications carry the risk of side effects. So healthcare professionals must balance the possible risk of a medication against the possible benefit. In a pregnant woman, that requires considering the effect of an untreated mood or psychiatric disorder on a fetus or developing child against the risk of medication-related birth defects or other problems after a child is born.

"It's safe to say that there are clearly changes in babies who are exposed to depression in utero," says Carl P. Weiner, MD, professor and chair of obstetrics and gynecology at the University of Kansas School of Medicine and coauthor (with Kate Rope, Seleni editorial director) of The Complete Guide to Medications During Pregnancy and Breastfeeding. "A mother who is sick and has trouble functioning in her everyday life is a danger to her fetus. It is far better to treat her so she's relatively functional than to subject her and her fetus to the consequences of untreated depression."

Some newborns exposed to SSRIs and SNRIs in utero may experience mild withdrawal symptoms, such as jitteriness, high-pitched crying, feeding difficulties, irritability, and possibly respiratory distress. These symptoms generally go away within several days without additional treatment, and Smith adds that similar symptoms have also been reported in newborns of mothers with untreated depression. "It can be difficult to separate out the effects of medication exposure from the effects of maternal depression," she says.

Finding the right medical care
"My recommendation for each woman struggling with depression during pregnancy is to have a consultation with a psychiatrist fluent in treating pregnant women," says Smith. "The consultation should include a thorough discussion of her specific case and the risks and benefits associated with treatment options, including lack of treatment."

A good place to look for a provider experienced with perinatal mood disorders is Postpartum Support International, an organization which operates a network of local coordinators who can help you find qualified professionals in your area. Also, your obstetrician should be able to suggest local treatment resources. Once you find a qualified provider, ask as many questions as you need to feel comfortable.

Making the best decision for you
The treatment of prenatal depression is highly individual. Rosalind Gillis, 39, chose to stop taking antidepressants during both her pregnancies after her doctor recommended that she research the pros and cons of going off her medication.

"It was extremely tough during the first few months of pregnancy with all the hormones," recalls Gillis. "But after the first trimester, I felt great and loved being pregnant." Soon after delivery, sensing that her mood imbalance would return, she began taking antidepressants again.

If you are facing the same choice, talk with your healthcare provider about the severity and type of mood disorder you are dealing with, including your psychiatric history, your response to past treatments, your family medical history, and your diet and lifestyle.

"Many people have concerns about using medication during pregnancy. This is completely understandable," says Bergeron. "It's important to note that the risks of exposing a baby to a severely depressed parent may be higher than exposing a baby to some amount of medication. In cases where the symptoms are mild to moderate, the choice of whether or not to use medication should be up to the patient. If the symptoms are severe, however, I strongly urge patients to seek medication as part of their treatment."

Quitting antidepressants, and then starting again after delivery, worked well for Gillis. Brooklyn mom Jennifer B., credits staying on antidepressants through both her pregnancies with "surviving those nine months." She sometimes wonders whether that decision impacted her son, who had depressed breathing at birth and had to spend several nights in the NICU.

But it's not known whether that resulted from her medication use, and she remains confident in her choice. "I don't regret staying on meds. I don't think I could have done it without them," says Jennifer. "I look at it as if I had cancer and needed to do chemotherapy. It took me many years to come to this: I had to do this to keep my body healthy."