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Visions Journal

A reminder that this article from our magazine Visions was published more than 1 year ago. It is here for reference only. Some information in it may no longer be current. It also represents the point of the view of the author only. See the author box at the bottom of the article for more about the contributor.

Antidepressants in Pregnancy and Lactation

Let’s look at the facts

Wende Wood, BA, BSP, BCPP

Reprinted from the "Medications" issue of Visions Journal, 2007, 4 (2), pp. 26-27

Generally speaking, I’m a big fan of irony, but not when it comes to important clinical issues. Despite all of the focus these days on evidence-based medicine, I’m continually shocked and disturbed by all the pronouncements that are made about the risk of antidepressants in pregnancy and lactation without, in my opinion, any appropriate evidence to back up those claims.1,2 I’ve lost track of the number of times I’ve had to reassure women who’ve been admonished by family members or even their healthcare providers— including their psychiatrists and/or pharmacists—for continuing an antidepressant while they were pregnant or breastfeeding. Please tell me, exactly what evidence is this based on?

In 2001, Motherisk published a small study that mirrors my experience and frustration. When consulted by patients regarding the use of medication in pregnancy, more than 90 per cent of pharmacists referred patients to their physicians, 60 per cent consulted the product monograph,† and only 14 per cent referred to current medical literature.3 Is this the best we can offer??

We need to remember that a monograph is a legal document reflecting agreed to facts between Health Canada and the pharmaceutical manufacturer, and is often a poor reflection of current literature and clinical practice. Fetal Risk Factor* assignments (A,B,C,D,X) decided upon by the U.S. Food and Drug Administration (FDA) and commonly cited by clinical textbooks are widely recognized as oversimplifications, and this system of rating safety is currently under review. Lastly, pharmacists can often interpret the medical literature for patients as well as— if not better than—physicians can. We can also give the woman some unbiased and up-to-date information to take with her to discuss with her physician.

So what do we know about the safety and risks of antidepressants in pregnancy? There does not appear to be any teratogenic* risk in terms of major deformities. Yes, a small percentage (probably less than five per cent) of babies can be born with withdrawal symptoms. This is more likely when multiple medications are involved and, even in the most severe cases, the symptoms resolve within days with no known long-term sequelae.* And while it’s true that we don’t know what effect, if any, antidepressant use will have on long-term intellectual development in children, so far, no problems have been identified.

And what do we know about the risks of untreated depression? We know that some common consequences include increased risk of miscarriage, premature delivery, low birth weight and low Apgar scores.* Moreover, a mother who is depressed may not be able to properly interact with her baby, and we know that poor bonding and lack of infant stimulation can lead to intellectual and emotional problems both in infancy and in later life. Depression in the mother can also lead to malnutrition and substance use for self-medication, which clearly have consequences for both the woman and baby. In severe cases, untreated depression, including post-partum depression, can be devastating. Yet, despite media reports of tragic cases of untreated or undertreated post-partum depression, people still don’t seem to comprehend the importance of this issue.

Of course, it is best if a woman can be treated with some form of psychotherapy or supportive counseling instead of an antidepressant, but this isn’t always appropriate or possible. We need to look at the risk/benefit ratio and weigh a small chance of treatable withdrawal symptoms and a very theoretical concern of mild intellectual delay against very known, very real, possibly devastating effects of untreated or undertreated depression.

If a decision is made to try going without an antidepressant, one of the more useful approaches I have found is for the woman to make an informal contract with herself, in which she writes down a list of symptoms that she would consider severe enough to restart antidepressant treatment. Indecisiveness can be an important symptom in depression, and it can be next to impossible to decide whether or not to restart an antidepressant while having moderate to severe symptoms. If, at that time, she can read her own words written when her symptoms were mild, it can help the process.

Often the mother feels she is being made to decide between her health and that of her baby. She may think, or even be told, that she should just ‘put up’ with the depressive symptoms rather than expose her baby to psychotropic medications. This whole mindset is based on the completely false assumption that the mother can disassociate her health from that of the baby. It must be emphasized that the most important determinant of health for a baby is the health of the mother.

In the end, of course, each case must be evaluated on an individual basis, and all treatment options should be considered. Depression is a serious and multifaceted disorder, and treatment should usually involve more than one modality. The last thing I want to imply is that all women with depression during pregnancy or lactation should take an antidepressant. Rather, my sincere hope is that they can have access to all of the facts and treatment options without the stigma, shame and guilt many of them currently face.

 
About the author
Wende is a Board Certified Psychiatric Pharmacist currently working at the Centre for Addiction and Mental Health in Toronto, Ontario. She is co-editor of the booklet Is it Safe for My Baby?
Note:

Originally appeared and reprinted with permission from Pharmacy Practice, 2005, Vol. 21, No. 7, pp. 6-7

Footnotes:
  1. Health Canada Warning: Health Canada advises of potential adverse effects of SSRIs and other anti-depressants on newborns. August 9, 2004. www.hc-sc.gc.ca/english/protection/warnings/2004/2004_44.htm.

  2. Press release: SOGC concerned about Health Canada’s advisory on SSRIs. The Society of Obstetricians and Gynaecologists of Canada, August 11,2004. sogc.medical.org/sogcnet/sogc_docs/press/releases2004/pdfs/2004/SSRIWarning_Aug2004.pdf

  3. Lyszkiewicz DA, Gerichhausen S, Bjornsdottir I, et al. Evidence based information on drug use during pregnancy: a survey of community pharmacists in three countries. Pharmacy World & Science 2001; 23(2):76-81.

 

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