Antidepressants and Pregnancy

Norman Sussman, MD

Editor, Primary Psychiatry and Psychiatry Weekly, Professor of Psychiatry, New York University School of Medicine

Antidepressants are among the most commonly prescribed psychotropic agents. They are used to treat not only mood disorders but many anxiety disorders as well. Most users of these agents are young and female. An increasingly common dilemma is whether to continue taking these medications during pregnancy.

Anxieties have been heightened by a series of recent reports and FDA labeling changes citing possible risks associated with the use of SSRIs and SNRIs:

1. Epidemiologic data suggest an increased risk of cardiac malformations associated with paroxetine exposure in the first trimester, resulting in a category label change for paroxetine from C to D.
2. Dr. Christine Chambers, and colleagues, found a risk of persistent pulmonary hypertension in newborns whose mothers had taken SSRIs. http://content.nejm.org/cgi/content/abstract/354/6/579
3. In response to findings that suggest that exposure to SSRIs or SNRIs late in the third trimester may be linked to multiple health problems in the newborn, the FDA has recommended that antidepressant pregnancy exposure risks should be described in patient labeling .

Neither the patient nor the prescriber should ever feel that taking these medications is risk free, and there must be a discussion of available evidence. However, it is important to keep a perspective about this issue. To begin with, psychotropic drugs should only be continued in any patient if the benefits of treatment clearly outweigh the risks. For most of the agents used to treat mental disorders, the risks to the fetus remain unclear. Despite recent warnings about the SSRIs and SNRIs, few experts in the field report seeing any sign of major complications related to these agents. Even less is known about the effects on the developing fetus of medication discontinuation, especially with drugs that produce a withdrawal syndrome. It should be kept in mind that for patients with chronic mental disorders, discontinuing medication predictably results in a return of symptoms, and studies have found that maternal stress and depression can have an adverse impact on a child’s social and educational functioning, as well as on neonatal incomes.

What path should a clinician follow? It is advisable neither to reflexively recommend that medication be stopped nor to be overly reassuring that risks do not exist. While it is understandable that a clinician might want to avoid potential litigation should there be a problem with the newborn, reflexively discontinuing medication does not consider the well-being of the mother or the fetus.