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.

A. Over the last decade, research has supported the use of certain selective serotonin reuptake inhibitors (SSRIs) and the older tricyclic antidepressants during pregnancy, indicating no increase in risk for congenital malformations in children exposed to these medications in utero. More recent studies, however, have raised questions regarding the risk for adverse events in newborns exposed to antidepressants around the time of labor and delivery (see Fall 2004, Spring 2005, and Spring 2006 Newsletters). Most commonly these studies have reported symptoms of jitteriness, irritability, sleep disturbance, feeding problems, and excessive crying in infants shortly after delivery. There have also been reports of respiratory distress (usually tachypnea or rapid breathing). In general, the symptoms observed have been brief, in most cases resolving within 1-4 days without any specific medical intervention. While the majority of these studies have observed relatively benign symptoms in antidepressant-exposed infants, one study has suggested that infants exposed to antidepressants late in pregnancy may be susceptible to a more serious form of respiratory distress associated with persistent pulmonary hypertension of the newborn or PPHN (Chambers et al, 2006).

Given the concerns that antidepressants taken late in pregnancy may cause a spectrum of adverse events in the newborn, some experts in the field have suggested that women discontinue antidepressants several months before delivery. While this approach may potentially reduce the incidence of toxicity in the newborn, it carries certain risks. Most women who make the decision to use antidepressants during pregnancy have histories of recurrent or severe depression, and their decision to maintain treatment with a medication has been driven by their inability to remain well without it. For these women, withholding medication is likely to increase the risk of depressive illness in the mother.
Depression is never a benign event. Pregnant women who are depressed are more likely to receive inadequate prenatal care and are more likely to use tobacco, alcohol, and recreational drugs, behaviors that may place the pregnancy at risk. Depression during pregnancy has also been associated with increased risk of preterm labor, lower birth weight, smaller head circumference, and lower Apgar scores (Bonari et al, 2004). Keeping these risks in mind, some women with depression may make the decision to continue treatment with an antidepressant, acknowledging that while there may be some risks associated with exposure to the medication, there are also significant risks associated with untreated depression.

Ruta Nonacs, MD PhD

Bonari L et al. Perinatal Risk of untreated depression during pregnancy. Can J Psychiatry 2004; 49 (11): 726- 735.

Chambers et al. Selective Serotonin Reuptake Inhibitors and risk of persistent pulmonary hypertension of newborns. New Eng J Med 2006; 354: 579- 587.

*This post was originally published as an article in the July 2006 Newsletter.