SSRIs and Pregnancy: Putting the Risks into Perspective

Depression is common during pregnancy, affecting 10% to 15% of women. While psychotherapy is an attractive option for the treatment of depression during pregnancy, all women do not respond to this intervention and many require pharmacotherapy. Thus far, no antidepressants have yet been approved by the FDA for use during pregnancy. Although data accumulated over the past 30 years suggest that certain medications, including the serotonin reuptake inhibitors (SSRIs), may be used safely during pregnancy, several new studies have raised concerns regarding the use of these medications during pregnancy.

A recent article published in the Psychiatric Times reviews the risks of antidepressant use in pregnant women.

In choosing an antidepressant for use during pregnancy, the clinician should attempt to select a medication that has a well-characterized reproductive safety profile. Fluoxetine, with the most extensive literature supporting its reproductive safety, is a first-line choice. There is growing literature on the reproductive safety of the newer SSRIs. Although SSRIs are the antidepressants most commonly used in this setting, there are data that support the use of tricyclic antidepressants (TCAs). While several studies outlined here suggest that there may be a small increase in the risk of certain malformations, it is felt that the absolute risk is low and that treatment is warranted when the risks of depression are thought to outweigh the risks associated with drug exposure.

In a recent editorial, Michael F. Greene, MD, of the division of maternal and fetal medicine at Massachusetts General Hospital in Boston, noted that these newer—and often conflicting—studies clearly have made it more difficult to make decisions regarding the treatment of depression during pregnancy. He noted further that “patients and physicians alike would prefer it if there were clear lines separating risk and no risk and if all studies gave consistent results pointing in the same direction.”

While these more recent reports have raised concerns, the data, taken as a whole, are reassuring and indicate that the risks associated with SSRI exposure during pregnancy are low.

Ruta Nonacs, MD PhD