Over the last decade information has accumulated regarding the safety of antidepressants taken during pregnancy. While much research has addressed the effect of antidepressant drugs on risk for congenital malformation, less research has focused on the long-term effects of prenatal antidepressant exposure.
While pregnancy has traditionally been considered a time of emotional well-being, recent data indicate that about 10% to 15% of women experience clinically significant depressive symptoms during pregnancy. Furthermore, women with a history of major depression appear to be at high risk for recurrent illness during pregnancy particularly in the setting of antidepressant discontinuation. In a recent study researchers from the University of Michigan report that while depression affects many women during pregnancy the majority of women suffering from this illness do not receive adequate treatment.
After the birth of a child, it is common for women to experience some type of mood disturbance. Typically, it is relatively mild (postpartum blues). However, about 10-15% of women experience a more severe and disabling illness, postpartum depression. It has been suggested that women who develop postpartum depression may be more sensitive to the hormonal changes that take place after delivery and that these hormonal changes may contribute to emergence of depressive symptoms during the postpartum period.
Q. I have been taking antidepressants on and off for the last ten years, and I am now planning a pregnancy. I am now on Effexor, and my psychiatrist recommended switching to Prozac and staying on it up until the end of the second trimester. He said that antidepressants should be avoided later on in pregnancy because they may cause problems for the baby at the time of delivery. I am concerned about having to come off my medication for such a long time. In the past, every time I have tried to stop the medication, my depression has come back within a month or so.
Driven by concerns regarding fetal exposure to psychotropic medications, many women with psychiatric illness attempt to discontinue their pharmacologic treatment during pregnancy; however, recent studies indicate that this approach may not be appropriate for all women. Dr. Adele Viguera and her colleagues at the Center for Women’s Mental Health have reported that among pregnant women with bipolar disorder, relapse rates were very high (58%) in women who discontinued maintenance treatment with lithium during pregnancy (Viguera et al 2000). Given this risk of recurrent illness, many women may consider continuing lithium treatment during pregnancy. While the teratogenic effects of first trimester exposure to lithium have been well studied, data on the long-term outcome of children exposed to lithium during pregnancy are sparse. At the 61st Annual Meeting of the Society of Biological Psychiatry in Toronto, Dr. Viguera presented preliminary data on the neurobehavioral outcomes of children exposed to lithium in utero.
Early reports suggested that women with bipolar disorder may be at lower risk for onset or relapse of this disorder during pregnancy and that some women may be able to remain well during pregnancy despite medication discontinuation. However, more recent studies have suggested that recurrence of affective illness during pregnancy is relatively common among women with bipolar disorder. Dr. Adele Viguera and her colleagues at the Center for Women's Mental Health reported that among pregnant bipolar women, relapse rates were very high (58%) in those women who discontinued maintenance treatment with lithium during pregnancy (Viguera et al 2000).
Q. I have taken Paxil for about six years for depression and obsessive-compulsive disorder. I have tried several times to stop the medication but the symptoms come back within a few weeks of stopping the medication. My husband and I are now planning a pregnancy, and my obstetrician tells me that I cannot take Paxil during pregnancy. Are there any other options?
A recent report suggests that newborns exposed to selective serotonin reuptake inhibitors (SSRI) antidepressants such as Prozac, Zoloft, Celexa and Paxil may be at risk for developing withdrawal symptoms after delivery (Levinson-Castiel 2005). However, the investigators also noted that the symptoms usually disappeared within 48 hours and did not require medical intervention.
Over the last decade, the number of reproductive-age women treated for depression has increased significantly. Given the incomplete information available regarding the reproductive safety of many antidepressant medications, many women choose to discontinue pharmacologic treatment during pregnancy. However, several studies estimate that about 10 to 15% of women suffer from depression during pregnancy (O'Hara et al, 1990; Evans et al, 2001). A recent study from the Center for Women's Mental Health indicates that the risk for depression is particularly high among women with histories of major depression (Cohen et al, 2006).
Literature accumulated over the last decade supports the use of certain selective serotonin reuptake inhibitors (SSRIs) and the older tricyclic antidepressants during pregnancy, indicating no increased risk of congenital malformation in children exposed to these medications during the first trimester of pregnancy. Still, questions remain regarding the purported risk for "toxicity" in newborns exposed to antidepressants around the time of labor and delivery. Several recent studies have suggested that exposure to SSRIs at the time of delivery may be associated with poor perinatal outcomes (Casper 2003, Laine 2003, Simon 2002, Zeskind and Stephens 2004) and prompted the FDA to include warnings in the packaging inserts regarding the use of certain antidepressants, including the selective serotonin reuptake inhibitors (SSRIs) and venlafaxine (Effexor), during pregnancy. These studies have been reviewed previously on the CWMH website (Newsletters Fall 2004 and Spring 2005).
