We tend to think of expectant mothers as literally glowing with health, even when they're lurching out of bed come morning to throw up into the toilet bowl. But falling pregnant doesn't magically cure you of anything, least of all depression and anxiety. Depressed women become pregnant, and healthy pregnant women can become depressed.
When it comes to medicating these symptoms, both groups face a conundrum. There is ongoing evidence that antidepressants—specifically selective serotonin reuptake inhibitors (SSRIs) like Zoloft, Prozac, Paxil, and Celexa—can adversely affect the health of unborn children.
Like many medications taken during pregnancy, SSRIs cross the placenta and enter the fetal circulation.
This is an uncomfortable thing to reckon with, because giving up medication while riding the pre-childbirth hormonal roller coaster poses mental health risks that are impossible to ignore. Chronic depression can be fatal, and is thought to affect up to 13 percent of pregnant women. And there's mounting evidence that an untreated mental disorder can harm both a mother and her unborn child.
In light of this, a growing body of medical research is examining the possible link between birth disorders and popular SSRIs. Like many medications taken during pregnancy, SSRIs cross the placenta and enter the fetal circulation—so their potential impact has been a source of medical interest for some time.
In 2005, the US Food and Drug Administration published an official warning about the association between one paroxetine (Paxil), and infant heart defects. Since then, various studies have addressed a range of possible birth defects that affect heart function, cognitive function, and speech and language functions.
For example: a new study published last month found that the children of mothers who had depression-related psychiatric illnesses, and who had purchased SSRIs (the authors did not differentiate between different types) at least twice when pregnant, were at an increased risk of having speech and language disorders.
Their findings do provide cause for concern, but the researchers behind the study say they're very reluctant to imply causality, or tell pregnant women to stop using SSRIs outright. Dr Alan S. Brown from Columbia University, who led the research, tells Broadly he didn't want it to cause women alarm. "I don't think women should be worried about our findings," he says. "But I think it's something pregnant mothers and doctors need to take into account—and consider all the options. Mothers should not automatically go off their medication, because that can have serious consequences as well."
Brown's advice is only somewhat comforting, but it does echo that of other researchers who have examined the possible adverse effects of SSRIs on unborn children. Take a 2015 study that suggested birth defects occurred up to 3.5 times more frequently among the children of women who used paroxetine (Paxil) or fluoxetine (Prozac), during early pregnancy.
This, too, sounds bleak. But one of the study's authors, Dr Jennita Reefhuis—a fellow at the National Center on Birth Defects and Developmental Disabilities—tells Broadly the same thing: that women should be aware of the possible risks, but not rash in their decisions to go off the meds. "Depression can be very serious and many women need to take medications during pregnancy to appropriately manage their symptoms," she says.
What's interesting about the British Medical Journal Study is that while it links Paxil and Prozac to birth defects, it refutes previous studies which have linked Zoloft with birth defects. "Reassuringly, we found that the five earlier reported links between specific birth defects and Zoloft were not found again. This was especially encouraging given the fact that it is the SSRI that was most commonly used among mothers who had a child without a major birth defect," Reefhuis explains.
This discrepancy highlights how contested this field of research is: There are no definitive answers just yet. Reefhuis says that she hopes further research will help distinguish the differences between different types of SSRI in terms of their foetal impact.
It may well be that in future, as the body of research grows, expectant mothers will know with more certainty which brands of antidepressant will be safer for their baby. Of course, this presents further issues: as anyone who has medicated their depression will tell you, the effects of one brand of SSRI compared to another can differ wildly between patients.
Perhaps one of the most alarming recent studies into a link between SSRIs and birth defects was authored by University of Montreal researchers in 2015. Released with the rather incendiary headline "Taking antidepressants during pregnancy increases risk of autism by 87%", the study examined the outcomes of 145,456 pregnancies after antidepressant use. It found that the risk of giving birth to a child with autism was one percent among women who didn't take antidepressants during their pregnancy, but 1.87 percent among women who did (during their second and third trimester). That's an increase of 87 percent.
We found SSRI use during the second and third trimester was increasing the risk of autism above and beyond the risk associated with maternal depression.
Lead author and pharmaceutical expert Dr Anick Bérard tells Broadly the findings were crucial because they showed the effects of taking SSRIs during pregnancy were far worse than those of maternal depression, which has also been found to adversely affect cognitive development. In fact, untreated maternal depression has been associated with preterm births, stillbirths, and low birth weight.
So antidepressants might be bad for your baby, but going off them might be bad for your baby too. It's a gut-wrenching Catch-22, but Bérard believes the former is the bigger concern. "We found that SSRI use during the second and third trimester of pregnancy was increasing the risk of autism above and beyond the risk associated with maternal depression," she says. "Maternal depression and SSRI use were independent risk factors for autism."
So, unlike other researchers Broadly approached, Bérard is firm in her advice that SSRIs are potentially dangerous to unborn mothers in their second and third trimesters. "Given the mounting evidence showing increased risk of adverse pregnancy outcome with antidepressant use during pregnancy, our study shows that depression should be treated with other options [other than antidepressants] during this critical time period," she says.
"Indeed, 80-85 percent of depressed pregnant women are mildly to moderately depressed; exercise and psychotherapy have been shown to be efficacious to treat depression in this sub-group... we acknowledge that depression is a serious condition but that antidepressants are not always the best solution." Bérard also notes that her study, which like others discussed distinguishes SSRIs from other antidepressants, makes some degree of biological sense. "Serotonin is essential for brain cell development and inhibition of serotonin reuptake by SSRI will perturb brain cell development," she says.
So what to believe? Ian Jones is a clinical professor at Cardiff University, specialising in the relationship between mood disorders and childbirth. He tells Broadly that the research surrounding SSRIs and pregnancy is useful, but not necessarily conclusive.
"It's important that we have these studies," he says. "And there is an association in some of them between being on antidepressants and problems in the pregnancy, and with the baby. But there are a number of reasons that may lead to this link." Women suffering from depression, Jones says, may experience a host of problems unrelated to their medication that can hurt an unborn child. "Things such as poor diet, obesity, or the effect of the illness for which the medication is being taken."
It's worth noting too that all the studies cited here relied on population data as their basis—in other words, they weren't examining pregnant women with depression up close. Which means they weren't witness to a bunch of factors that might affect the outcome of a pregnancy.
Deciding how to juggle mental health and pregnancy is tricky, and a medley of slightly confusing, somewhat inconclusive medical studies don't make things much easier. So while it makes sense to get informed—and consult your doctor before making any rash decisions about your SSRIs— it's also worth noting that none of this is proscriptive.
"These are very difficult decisions for women and their partners," Jones says. "For some women, taking medication may be the best option for them and for their baby—having a severe episode of [depressive] illness in pregnancy may itself not be the best for the child.
"But there are no right and wrong answers, and it's important to make the decision with a woman in light of her particular history of mood episodes and response to treatment."