There's a dirty little secret about pregnancy: It's not always the magical experience that it's made out to be.
In fact, up to 20 percent of women experience depression during pregnancy. For some of them, that means a difficult choice: choosing to take antidepressants – as roughly 13 percent of women with pregnancy depression do – or avoiding medications "for the baby's sake."
"You always have to weigh the risk of medication against the risk of illness," says Pec Indman, Ed.D, MFT, co-author of Beyond The Blues: Understanding and Treating Prenatal and Postpartum Depression & Anxiety. A mom-to-be's depression can have a very real, negative effect on her health and the health of her growing baby. Read on to learn if antidepressants, such as Prozac, are safe for pregnancy.
If you've already been taking an antidepressant before becoming pregnant, you may think you'll need to go off your medication, but that's not necessarily true. "It's important to talk to your doctor before stopping or switching any medication," stresses Lucy Puryear, M.D., psychiatrist and medical director with The Women's Place Center for Reproductive Psychiatry at Texas Children's Pavilion for Women in Houston and associate professor of obstetrics and gynecology at Baylor College of Medicine in Houston.
If your depression develops during pregnancy, your course of treatment will depend on your level of depression, says Shelly Cohen, M.D., J.D., a consulting psychiatrist at the Seleni Institute, a nonprofit organization that offers psychotherapy and emotional and practical support to women and moms in New York City. In general, medications are considered when depression enters the moderate-to-severe range, includes suicidal thoughts, or when a woman has a history of severe depression.
The question of taking antidepressants during pregnancy is a highly debated topic. No doctor can say with 100-percent confidence that the drugs are completely safe. Nor is there any one particular antidepressant that's considered "safest" for pregnant women, although Wellbutrin and selective serotonin reuptake inhibitors (SSRIs) such as Zoloft, Prozac, Lexapro, and Celexa are the most commonly prescribed antidepressants for pregnant women, Dr. Puryear says.
Although there's a wealth of research focusing on SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs), due to ethical regulations, most of the data looks at pregnant women who have already taken the medication. That means that the data is limited, because other factors – for example, if the pregnant women smoked or used alcohol – may have come into play. That's why it's impossible to say if the drugs are 100-percent safe – and why most drugs are prescribed based on a doctor's comfort level and what works for the patient.
One common fear about taking antidepressants during pregnancy is that they may increase the chance of birth defects in babies. But aside from Paxil, which Dr. Cohen says is controversial for risks of cardiac complications, SSRIs have not, on the whole, been linked to an increase in birth defects above the baseline risk.
Even so, two recent studies have raised other concerns about the use of antidepressants during pregnancy: A paper published in the March 2014 issue of the journal PLOS One found a link between preterm birth (defined as earlier than 37 weeks) and antidepressant use. The study found a 96 percent higher risk of preterm birth for women who had taken antidepressants during their final trimester. But doctors aren't quick to point the finger at medication just yet. "This study reinforces what we have known is a potential risk of using antidepressants during pregnancy, which is late preterm birth," states Christina Treece, M.D., a psychiatrist with The Women's Place Center for Reproductive Psychiatry at Texas Children's Pavilion for Women and Assistant Professor with the Menninger Department of Psychiatry at Baylor College of Medicine in Houston. She notes that the study is "not conclusive" and adds that untreated depression is also a risk for preterm birth.
Another study, published in Pediatrics, showed that prenatal exposure to SSRIs, especially during the first trimester, may "increase susceptibility" to certain forms of autism spectrum disorders in boys. But Dr. Cohen stresses that this shows an association between an increased risk for autism and SSRI use in pregnancy, and not a cause-and-effect relationship.
What these studies do highlight is the need for pregnant women and their doctors to carefully consider the risks of treating depression with medication versus the risk of the mother's illness, Dr. Treece says. Changes to medication ideally should happen before conception so you have time to adjust. Ultimately, only you and your physician can determine what's best for you.
Of course, there are potential side effects from all antidepressants, and for babies, these can include: changes in birthweight, premature labor, a serious but very rare condition called persistent pulmonary hypertension of the newborn, and a disorder called neonatal adaptation syndrome, which antidepressant-exposed newborns have a 10-to-30 percent chance of developing. (The condition clears up on its own, but can result in fussiness, poor feedings, respiratory difficulty, and, in rare cases, seizures.)
Not seeking treatment can be risky, too. Despite the potential negative side effects of taking antidepressants during pregnancy, it's important to realize that not treating depression can have serious consequences for mom and baby.
With her depression left untreated, a mom-to-be may be more likely to not take good care of herself physically, and may take more over-the-counter medications, Dr. Cohen says. She may also be more likely to abuse drugs and alcohol and to smoke. "There can be poor outcomes with untreated depression," Dr. Cohen adds. "So you have to weigh the risks and benefits of treating with risks and benefits of not treating the illness."
Adds Dr. Puryear: "Given the stigma toward mental illness, women are often more reluctant to take psychiatric medication while they are pregnant. Somehow they have the idea that they 'should' be able to manage without it in order to protect their baby, but no one has this expectation for any other serious medical illness; women take medication for many different illnesses, including hypertension, asthma, rheumatoid arthritis, and others. Depression is no different."
Never discontinue medication without consulting your physician first. Here are some questions to ponder before you do:
1. How severe is my illness? Women who have had four or more major depressive episodes before pregnancy or an episode within the last six months are most likely to relapse if they discontinue medication during pregnancy, according to a study published in Epidemiology.
2. Have I gone off medication before and relapsed? Some women know they'll get sick if they wean off their medication, Yonkers says.
3. Have I tried psychotherapy? Depression-focused psychotherapy can be very effective, research shows. Ask your doctor for recommendations, or find one via the American Psychological Association (apa.org).