Many women with a history of depression who take antidepressants assume that once they get pregnant, they should try to wean themselves off their meds to avoid negative side effects for the baby. A new large study published in the journal Pediatrics challenges one reason behind that assumption. The research found that taking selective serotonin reuptake inhibitors (the antidepressants also known as S.S.R.I.s) while pregnant does not increase the risk of asthma in the resulting babies. What is associated with an increased risk of asthma? According to this study and other research, untreated prenatal depression.
“The mechanisms underlying the association of prenatal depression and asthma are unknown,” said Dr. Xiaoqin Liu, the lead author of the Pediatrics study and an epidemiologist at Aarhus University in Denmark. An association between prenatal depression and asthma does not mean that prenatal depression causes asthma. There could be other reasons for the correlation, genetic or environmental, or both. For example, people who live in dense, polluted urban areas could be at an increased risk of both asthma and depression.
The researchers used Denmark’s national registries to evaluate all singleton babies born from 1996 to 2007, and identify the mothers who had a diagnosis of depression or had used antidepressants, or both, during pregnancy or one year beforehand. Using a statistical model, the study authors found that prenatal depression — with or without the use of antidepressants — was associated with a 25 percent increased risk of asthma in children as compared with children whose mothers did not have a record of depression.
This is an important finding for any pregnant (or soon-to-be-pregnant) woman struggling with symptoms of depression and wondering whether she should or should not take the antidepressants she may sorely need. “This points to the fact that depression alone can lead to adverse outcomes in the offspring; we still have to weigh the risks of not treating,” said Dr. Rebecca Starck, chairwoman of regional obstetrics and gynecology at Cleveland Clinic. And in this instance, with regard to asthma, the research found that treating with S.S.R.I.s do no harm.
Of course, there is no shortage of research examining the possible health dangers associated with prenatal antidepressant use. Many studies have found an increased risk of adverse outcomes such as low birth weight, birth defects, breathing problems, medication withdrawal and hyperactivity, among other things. And still other studies have found those risks to be insignificant or nonexistent with regard to most S.S.R.I.s. “For every study that finds a problem, such as preterm birth among babies exposed to antidepressants in utero, there are well-designed studies that do not replicate those risks,” said Dr. Kimberly A. Yonkers, professor of psychiatry, epidemiology and obstetrics and gynecology at the Yale School of Public Health. “Research hasn’t conclusively established that antidepressants are harmful to fetuses.”
So how are the 14 to 23 percent of pregnant women who experience depressive symptoms supposed to interpret this body of inconclusive research when it comes to making a decision about their health and that of their babies?
It’s not easy. And I say that as someone who has been there. I remember the agony of evaluating the perceived risks and benefits of taking S.S.R.I.s during pregnancy. Would I be causing my baby harm by exposing her to the medication? Or would she suffer more if I exposed her to untreated depression? I found myself bearing the guilt of a mother before I’d even borne a baby, made worse by the implicit judgment I felt for taking antidepressants in the first place.
“I think the controversy surrounding antidepressant use during pregnancy really has to do with the stigma of psychological illness,” said Dr. Jennifer Payne, associate professor of psychiatry and director of the Women’s Mood Disorders Program at Johns Hopkins School of Medicine in Baltimore. “People believe that if you have depression, you should pull up your socks and muscle through, and really that’s not the case. People do not understand how serious these illnesses can be — for mom and baby.”
Untreated prenatal depression is not only associated with an increased risk of asthma in children and postpartum depression in mothers, it is also linked to other negative outcomes such as preterm birth, low birth weight, irritability and elevated cortisol levels in babies, which may lead to mood disorders later in life. “People forget about the risks of not treating,” Dr. Payne said. “Antidepressants are the best studied class of medications during pregnancy, as far as I know, and over all, the risks of taking them during pregnancy are quite small whereas the risks of untreated depression during pregnancy are quite large.”
Because of the inconclusive research, other doctors weigh those risks differently. That’s one of the many things that makes this decision so difficult.
Small or large, both options — to take medication or not — warrant careful consideration. “The decision to take antidepressants during pregnancy should be done on a case-by-case basis, in partnership with a psychiatrist and after discussing other methodologies to manage symptoms, like psychotherapy,” Dr. Starck said. “And we need to be very cautious in identifying women to wean off antidepressants.”
For some women the treatment protocol will be clearer than for others. But what I find encouraging is that women have these options — and that mental illness is being studied and talked about. I hope we can keep the conversation going.