By Nadia Mohamedi, OTIS Teratogen Information Specialist
May is a beautiful month. Flowers are blooming, the birds are chirping and BBQ's are firing up. To me, however, May is most beautiful as it is Mental Health Month. This month we celebrate the spreading of awareness of mental health conditions and wellness, an issue that is near and dear to my heart. Although one in four Americans has a clinically diagnosable and treatable mental illness, a lack of awareness and a strong stigma associated with having a mental illness deters more than half of these individuals from seeking treatment.
One of the most frequent counseling calls we receive through our toll-free help line at the Organization of Teratology Information Specialists (OTIS) are from women wondering about depression and antidepressant use in pregnancy. In fact, depression occurs in up to 15% of pregnant women and about 13% of women in the United States report using an antidepressant in a pregnancy. Although the research data on the safety of antidepressant use and the risk of untreated depression in pregnancy has grown immensely in the last five years, the results can be difficult to interpret, especially in light of recent lawsuits. In this blog, I hope to summarize the recent data so women and their health care providers can make the best-informed decisions about their treatment plans in pregnancy. I also hope to increase awareness of this serious, but highly treatable, condition so that we can all support the mental wellbeing of our friends and family.
What is depression?
Now and then, everyone has the blues. When we lose a family member or experience a disappointment, it is normal to feel sad. When there is no specific reason for this sadness or it remains for too long, the cause could be depression. Experts feel that depression is caused by a combination of biological, psychological and social factors. Clinical depression is defined, by the DSM IV-TR, as at least a two week period in which a person experiences a decrease in previous functioning with either a depressed mood or loss of interest/pleasure in one's normal activities most of the time. Other symptoms can include change of weight/appetite, sleeping too much or too little, restlessness from mental tension, loss of energy, feelings of worthlessness or guilt, inability to concentrate and thoughts of death. There is a wide range of severity that can occur with depression.
How does untreated depression affect a pregnancy and the development of the fetus?
Untreated depression can affect a pregnancy in different ways. One of those ways is the direct effect of depression on one's behaviors. For example, a depressed pregnant woman is more likely to have poor nutrition, missed prenatal care appointments, or alcohol and drug use. These behaviors can be extremely detrimental for a developing fetus such as causing poor fetal growth, birth defects, preterm delivery, or neonatal withdrawal. Biological factors of depression like the irregularity of hormones can contribute to placental dysfunction or decreased uterine blood flow to the developing baby.
Since depression is a complex disorder, researchers have had difficulty discerning the specific causes of adverse pregnancy outcomes associated with untreated depression. For example, untreated depression can adversely affect one's stress level and social support. Nonetheless, many studies have shown that depression left untreated increases a woman's risk of adverse pregnancy outcomes such as preterm birth (delivering before 37 weeks), poor fetal growth, preeclampsia (a serious form of high blood pressure) and placental abnormalities. Moreover, women with depression who stop taking their medications are as much as five times more likely to have a relapse of symptoms compared to women who continue their medications in pregnancy.
Beyond the pregnancy, women who have a mental illness during their pregnancy are twice as likely to develop post-partum depression (PPD), depression following childbirth. PPD can adversely affect maternal bonding and the baby's development and behavior.
Now that we have the risks of untreated depression, what are the risks associated with treatment for depression in pregnancy?
The most common treatment for depression is taking an antidepressant medication. Most antidepressant medications have not been linked to higher risks for birth defects. When some antidepressants are taken during the third trimester, there may be effects in the newborn. The baby may be jittery, irritable, and have difficulties with feeding, sleeping, breathing and heart rate. In most cases, these symptoms last a few days or less. Some antidepressant medications have been studied more thoroughly than others. You may call OTIS toll-free at 1-866-626-6847 to speak with a counselor about your specific treatments and possible risks to a pregnancy.
IMPORTANT: You should not stop taking your medication without first consulting your physician. If you and your doctor decide that you should come off the medication, it is recommended to slowly taper off the medication to avoid possible withdrawal effects. Although it is generally recommended to take a medication that has the best pregnancy data and the lowest dose possible to treat your condition, it is not recommended to switch to a more researched medication if you are unresponsive to it. There's no point in exposing your baby to it if it doesn't help you! Also, you may have to increase your dose in pregnancy due to weight gain and hormonal changes. Despite the potential risks in late pregnancy, your doctor may want you to stay on your medication to avoid a relapse or prevent post-partum depression.
Other treatment options with no known risk to the developing baby are psychotherapy, light therapy, and acupuncture for depression. For other ways to help improve your symptoms and mentally pamper yourself, you can read a recent OTIS article: http://www.otispregnancy.org/news-s13020#143073.
Seems like so much information. How can I decide what to do?
Unfortunately, there is no easy answer for depression treatment in pregnancy. A long time ago, it was thought that having depression was impossible during pregnancy. Clearly, this is not the case. Mothers should feel neither guilty taking a medication that they need in order to maintain their normal functioning nor embarrassed that they are not feeling mentally well when everyone expects a pregnant woman to be glowing all over the place. In the end, no one knows your condition better than you and your physician. In general, a healthy mom is a healthy baby. So, this May, focus on YOU your mental well-being, your treatment, your support, and your future family. And know that all over the United States, others will be spreading awareness and encouraging others to live well this Mental Health Month.
**Nadia Mohamedi is a teratogen information specialist and also serves as a research assistant/interviewer for OTIS studies in San Diego, CA. She holds a BA in neurobiology and a minor in psychology from Harvard College. In addition to her work with OTIS, Nadia has worked for the Alcohol and Drug Abuse Treatment Program at McLean Hospital as well as served as a teacher's assistant at a school for children with disabilities in Lima, Peru.
OTIS is a North American non-profit dedicated to providing accurate evidence-based information about exposures during pregnancy and lactation. Questions or concerns about anti-depressants during pregnancy or breastfeeding can be directed to OTIS counselors at (866) 626-OTIS (6847) or online at OTISPregnancy.org.**
Bansil P, et al. 2010. Maternal and fetal outcomes among women with depression. J Women's Health.19(2): 329-334.
Cooper WO, Pont ME, Ray WA. 2007. Increasing use of antidepressants in 2 pregnancy. Am J Obstet Gyneco.l 196:544e1.
Muzik M, et al. 2009. When depression complicates childbearing: guidelines for screening and treatment during antenatal and postpartum obstetric care. Obstet Gynecol Clin North Am. 36:771-88.
Petersen I, et al. 2001. Pregnancy as a major determinant for discontinuation of antidepressants: an analysis of data from The Health Improvement Network. J Clin Psychiatry.