The pros and cons of taking antidepressants while
pregnant have been hotly debated despite increasing research in the field. Each
time one study highlights negative outcomes associated with antidepressant use
during pregnancy, another study is published pointing toward the benefits for
mother and baby.
For any woman considering pregnancy and in need of
antidepressants, deciding on a course of action can be agonizing. Today,
research published in JAMA Pediatrics is likely to make matters even more
troubling for these women.
The large observational study, led by Anick
Bérard, Ph.D., professor of perinatal epidemiology at the University of
Montreal, found that taking antidepressants - particularly selective serotonin
reuptake inhibitors, commonly called SSRIs - during the second or third
trimester of pregnancy is associated with an 87 percent increased risk of
autism spectrum disorder in children. That headline-provoking number represents
a relatively large associated increase in what begins as a small number: Among
the pregnancies studied, the rate of diagnosis of autism rose from less than 1
percent to less than 2 percent of children when the mothers were taking
antidepressants. The findings were based on all pregnancies in Quebec between
January 1998 and December 2009, and included 145,456 pregnancies that resulted
in full-term, singleton babies.
“We’re not the first paper on this topic, but
we’re the first one with such a large sample size,” said Dr. Bérard, who also,
as is disclosed in the paper, was a consultant for plaintiffs in the litigation
involving antidepressants and birth defects. “So of course it sounds alarming;
it’s almost two times the risk of autism.”
It certainly does sound alarming and no doubt may
frighten many would-be mothers, especially considering that from 14 percent to
23 percent of women experience depressive symptoms while pregnant. But it’s
important to put the numbers in perspective and remember that we’re still
talking about less than 2 percent of children. “The absolute risk in this study
is very small,” said Kimberly A. Yonkers, M.D., professor of psychiatry,
epidemiology and obstetrics and gynecology at the Yale School of Public Health.
I called Dr. Yonkers because the last time I
spoke with her (for New Research on Antidepressants and Pregnancy Finds No Link
to Athsma) about this topic, her take was that the jury was still out on
whether antidepressants are harmful to fetuses. So I wondered, would this new
study change her thinking?
“I don’t want to be an apologist for
antidepressants during pregnancy, but I always have to look with a certain
degree of skepticism at cohort studies - which I think are invaluable and I
have published them myself - but they also have issues,” said Dr. Yonkers, who
is also the director of the Center for Wellbeing of Women and Mothers at Yale.
One of the primary limitations of observational studies like these, she
explained, is that no matter how carefully researchers aim to evaluate each
risk factor, it’s often extremely difficult to tease them apart - particularly
in this case in which autism spectrum disorder and depression share some of the
same environmental and genetic risk factors.
And at this point, it remains unclear how
depression, antidepressants, genetics or other environmental factors may
interact to result potentially in a diagnosis of autism. Dr. Bérard, the study
author, was quick to point this out as well: “The causes of autism are still
unknown,” she said. “We’re starting to understand it but we’re far from really
understanding the whole mechanism. “We studied one of multiple environmental
causes and measured an association. It’s not a cause.”
Still, she added that this association is consistent
with some other observational research that has been published. And when it
comes to studying pregnancy and antidepressants, observational research is the
best we’ve got. Though randomized controlled trials are considered the gold
standard in determining cause and effect, they are not an option in this field.
It would be unethical for researchers to assign pregnant women randomly to one
group or another that could potentially harm a baby. When controlled trials are
unavailable (as they often are in issues of health) experts in this arena must
rely on observational studies and hope that once enough of them show similar
associations time after time, causal effects will start to emerge.
Take the example of smoking and lung cancer.
“There’s no doubt in anybody’s mind that smoking causes lung cancer,” said Dr.
Bérard. But that was not the case when researchers first began studying the
association between cigarettes and cancer. It took years of observational
research “with multiple studies of different populations with different
observational designs and with different limitations always showing the same
thing. And now there is no doubt that there is a causal association.” This kind
of research into pregnancy, she said, should be viewed as part of a growing picture
that is still far from complete.
It’s also far easier to reach a definitive
conclusion with respect to smoking - a recreational activity that doesn’t in
itself offer medical benefits. Suggesting that people may be better off
quitting is not likely to harm them, and may in fact help them. Taking
antidepressants, on the other hand, is an established treatment for very real
psychiatric conditions, and suggesting that the medications are dangerous to
fetuses - before all the observational evidence is in - could have disastrous
results.
“I have seen people terminate pregnancies because
they’re so psychiatrically ill and they’re afraid to be treated because they’re
afraid that their baby is going to be exposed to a psychotropic agent,” Dr.
Yonkers said.
What is more, “untreated maternal depression is
associated with a host of other complications,” wrote Bryan H. King, M.D.,
professor of psychiatry and behavioral sciences at the University of Washington
and the director of the Seattle Children’s Autism Center, in an editorial that
accompanies this new study. Research has found these complications to include
preterm birth, an increased risk of asthma in children and elevated cortisol
levels in babies, which may have lifelong effects on those children’s brains.
So then what are we to make of this new study?
Should it influence how pregnant women and their doctors approach
antidepressants? Perhaps, Dr. Bérard suggested, after noting that women should
talk with their doctors about their medications and options first. “We’re not
saying, ‘do not treat depression.’ We will never say that. It’s a very severe
and debilitating condition and is associated with a lot of co-morbidities,” she
said. “Of course treat depression, but maybe treat it differently, at least
during pregnancy.” She added that exercise and psychotherapy have each been
shown to help alleviate mild to moderate depression.
And what if exercise and talk therapy are not
enough? “What this says to me - and this hasn’t changed - is that people should
take a medication during pregnancy if they absolutely need it,” Dr. Yonkers
said. “If they don’t need it, they should not take it.”
It sounds simple enough. But it’s not always
simple to figure out if you need antidepressants. I speak from experience. I
took antidepressants during pregnancy after trying many other treatment
approaches. And even though I was armed with information and the benefit of
thoughtful health care providers, it was one of the hardest decisions I’ve had
to make in my life.
So, while I know that this study may make that
same decision harder for other pregnant women, my hope is that it does not
scare women from seeking treatment. Instead, I hope women and their clinicians
consider the entire body of research on depression and antidepressant use
during pregnancy to help guide women as they navigate their way into
motherhood.
Distributed by The New York Times
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