Should Pregnant Women Risk Mood Meds?

A new report offers guidelines on treating pregnant women with depression.

August 20, 2009, 7:34 PM

Aug. 21, 2009 — -- Until the 30th week, Suzanne Sevlie's second pregnancy had been progressing well and she was happy and healthy. But in the final weeks of her pregnancy, a close friend's death left Sevlie depressed and frustrated with her inability to connect with her unborn child.

"I thought I just don't feel right. I don't feel like I'm happy," Sevlie said. "There was a point where I literally felt like I wanted to cut my stomach out because I was so detached from the baby at that point."

Sevlie had experienced depression once before when she was 15, for which she received medication and counseling. But after high school and through her first pregnancy at age 23, Sevlie had no mental health issues. Her depression during her second pregnancy was a development she would not accept.

"I didn't take [medication] when I was pregnant because I didn't know there were any options," said Sevlie, whose obstetrician recommended monitoring when she told him how she felt. "I knew once the baby came I could do that if I wanted to... But I knew that if it got out of control it could have an effect on the baby and my family. I thought: this is not happening!"

Having depression during pregnancy puts everyone, from parents to clinicians, in a precarious position. Depression can be harmful to a mother and her developing baby. But taking antidepressants also pose risks since a fetus can be affected by any substance a mother introduces to her body.

Past guidance on depression during pregnancy has been mixed, with obstetricians and psychiatrists often offering conflicting advice on management. But a new report that combines recommendations from obstetricians and psychiatrists may mean that women are poised to receive better prenatal mental health care.

Today, the American Psychiatric Association and the American College of Obstetricians and Gynecologists released a collaborative report that sums up past research and is the first to offer concrete guidelines for treating depression in pregnant women. The report was co-published in the journals Obstetrics and Gynecology and General Hospital Psychiatry.

"[The report] is an excellent synthesis of what is known in the literature to date about the risks of both mood disorders during pregnancy and the risks of using antidepressants," said Sheryl Kingsberg, chief of the Division of Behavioral Medicine at University Hospitals Case Medical Center. "The basic guidelines have been to make the decision on an individual basis and to recognize that non-treatment of depression is not benign. I think it provides the 2009 update that has been needed."

Depression During Pregnancy Can Be a Major Problem

Between 14 and 23 percent of pregnant women experience depression during pregnancy and, as of 2003, 13 percent of pregnant women took antidepressants to combat the illness.

Based on criteria such as the severity of depressive symptoms, past success with psychotherapy and the patient's desire to be on medication, the report provided guidance on evaluation and treatment options for women with depression who wish to conceive or who are already pregnant.

For instance, the report advises that it is safe for some women to taper off medication before or during pregnancy if their symptoms are mild and they respond well to psychotherapy. In women with a history of severe, recurrent depression, however, or those with suicidal symptoms, refraining from medication is not advised as they may become a danger to themselves and their baby.

"There are a lot of people who don't know this information," said Dr. Sudeepta Varma, a psychiatrist at the New York University Medical Center. "It might come as a surprise to some that it's necessary to treat patients [with drugs] when they're pregnant. I think there are clinicians that shy away from it."

Though the prenatal risks of taking antidepressants are not fully known, the report stresses the potential negative impact of allowing depression to go untreated as a mitigating factor in the decision to medicate.

Depressed mothers are at increased risk of substance abuse, of poor compliance with prenatal care, and have poorer nutritional habits than mothers who are not depressed.

"You cannot separate the needs of the mother from the needs of her fetus," said Dr. Lucy Puryear, a reproductive psychiatrist and author of the book Understanding Your Moods When Your Expecting: Emotions, Mental Health, and Happiness—Before, During, and After Pregnancy. "To ignore the pregnant woman's mental health in order to 'protect' her baby causes distress to the pregnant mother and her family."

Some Oppose Antidepressant Use

Dr. Kimberly Yonkers, a psychiatrist at the Yale School of Medicine and lead author of the report, said there have been "a number of scares" regarding taking antidepressants during pregnancy.

"The majority of the literature has looked at the effects of depression on pregnancy... or looked at the effect of medication on pregnancy without considering the effect of the depressive symptoms themselves," she added.

But while some clinicians may sidestep the issue, certain groups strongly oppose using antidepressant medications during pregnancy.

"We're not in favor of women taking [antidepressants] when they're pregnant," said Amy Philo, co-founder of Children and Adults Against Drugging America (CHAADA) and "I don't know how people can logically believe that feeling sad when you're pregnant is going to cause [complications]."

Philo, who said she experienced suicidal and homicidal thoughts after being preemptively prescribed an antidepressant for post-partum depression, cited cardiac problems, fetal abnormalities, Sudden Infant Death Syndrome, and intra-uterine or neonatal death as potential risk factors of drug therapy.

"Definitely [antidepressants] can hurt the baby," Philo said. "We encourage people to get all the information that's out there and find support that is not drug oriented."

But Dr. Ruta Nonacs, a psychiatrist with the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital, said there is no scientific data to support that treating mothers with antidepressants leads to an increased risk of fetal abnormalities or death.

"I don't think there's some smoking gun out there that's been hidden," Nonacs said, adding that misinformation, fear and personal preference not to use drugs may be factors in deciding whether to use antidepressants. "It's a reasonable fear of harming kids which probably everybody has... that's gone awry."

Depression Can Lead to Lost Time With Children

And Sevlie pointed out that her experience with untreated depression during pregnancy as well as the eight months of post-partum depression she endured -- for which she did complete a course of treatment -- led to feeling alienated from her daughter.

"I feel like I lost that first year of her life," Sevlie said. "I don't remember when her teeth came in or when she sat up... I remember feeling I wasn't the mom I was supposed to be."

Over the course of her pregnancy and subsequent treatment for post-partum depression, Sevlie said her obstetrician and psychiatrist may have shared her medical charts but that neither asked what the other was advising her to do.

"I would have liked to know more of my options," Sevlie said. "Not just medications but outlets for depression and pregnancy support."

Experts stressed that some facets of the report highlight the need for more research on the risks of both depression and antidepressant treatment. But unified recommendations from both obstetricians psychiatrists should assist in more effective treatment for pregnant women with depression.

ABC News' Courtney Hutchison contributed to this report.

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