Antidepressants During Pregnancy: Stay on Them or Stop?

In December, two new studies on taking antidepressant drugs during pregnancy drew a lot of attention. The larger study, of nearly 850,000 births in Finland, found more short-term complications in newborns whose mothers used commonly prescribed antidepressants while pregnant. But the study also found benefits: lower risks of premature births and cesarean sections in women who took these drugs compared to women with untreated psychiatric disorders.

A Canadian study of more than 145,000 infants born in the province of Quebec found a link between antidepressant use during pregnancy and an increased risk of autism in offspring. But the study showed an association, not cause and effect, experts say, and the added risk is small.

Women with depression who become pregnant face questions with no single right answer. Here, experts talk about the pros, cons and uncertainties of drug treatment for depression in pregnancy.

Withdrawal Symptoms

The study of births in Finland, published in the American Journal of Psychiatry, involved antidepressants called selective serotonin reuptake inhibitors -- such as Prozac, Celexa, Paxil, Zoloft and Lexapro. Babies whose mothers took SSRIs during pregnancy showed higher rates of complications requiring time in a neonatal intensive care unit.

"The clear finding so far is that these offspring do have more breathing problems and likelihood of being in the ICU," says senior study author Dr. Alan Brown, a professor of psychiatry and epidemiology at Columbia University Medical Center. Withdrawal from antidepressant drugs, or "neonatal abstinence," is likely behind the short-term respiratory problems these babies have at birth, Brown says. While there's potential for later problems, he says, so far there hasn't been long-term research to show that.

Stress Effect

Untreated depression during pregnancy is bad for both the mother and developing infant, says Dr. Ruta Nonacs, an attending psychiatrist at the Center for Women's Mental Health at Massachusetts General Hospital. "People who are depressed have higher levels of cortisol and stress hormones," she explains. "And the baby is exposed to those higher levels of stress hormones."

The depressed mother's stress hormones can also cause an elevated risk of preterm labor, Nonacs says. The baby may have lower weight gain in pregnancy and be born small for gestational age.

For babies whose mothers are treated with antidepressants, withdrawal symptoms, if any, "tend to be short-lived and benign and don't require any type of intervention," Nonacs says. While these babies go into special care nurseries more often, she says, it's usually just for observation. "But they are just as likely to go home with Mom as kids who haven't been exposed to antidepressants," she adds.

Severe Depression

Severe depression, left untreated, can lead to serious consequences, Brown says, including risk of suicide for some patients. Women who are affected might not eat enough or sleep normally during pregnancy. Signs such as inability to function, marked weight loss and psychotic symptoms indicate it's unsafe for a woman to go off antidepressant treatment, he says.

Nonacs describes possible indirect effects on pregnancy: "Women with depression are more likely to smoke; they're more likely to use alcohol," she says. "They're more likely to use other medications -- not necessarily psychotropic medications, but others." With depression, she adds, women are less likely to exercise, follow a healthy diet or comply with prenatal care appointments.

Autism Question

The Canadian study, released online Dec. 14 in JAMA Pediatrics, looked at infants born over a decade. It found a link between women taking SSRI drugs and an increased risk of autism in their children. "Use of antidepressants, specifically [SSRIs], during the second and/or third trimester increases the risk of [autism spectrum disorder] in children, even after considering maternal depression," researchers found.

Dr. Bryan King, program director of Seattle Children's Autism Center and a professor of psychiatry and behavioral sciences at the University of Washington, wrote an accompanying journal editorial about the study. He also was interviewed in a Seattle Children's blog to put the findings into perspective for parents.

The study found an about 0.5 percent increased risk, King noted. "That is, for every 200 mothers who continue their antidepressants through pregnancy, there may be one additional child born with autism," he said. Rather than being definitive, he said, the new study "is just another brick in a path toward understanding risk factors associated with autism in general."

Brown, of Columbia University, says previous research on autism risk and prenatal exposure to antidepressants "is very, very mixed. There are more studies that say that it doesn't cause autism than it does cause autism."

Making Choices

Some women with mild to moderate depression may do well taking a break from medications during pregnancy. Other women might see symptoms return. If you're in this situation and deciding what to do, here are some considerations:

Informed consent. "It's important that the physician, regardless of what kind of physician, inform [women] completely about everything that's known on what this antidepressant can potentially do the child, as well as the risk of not getting treated," Brown says.

Questions to ask. "I would want to know: What are the risks, but also, what are my options?" Nonacs says. "If I decide to come off medications, is there anything I can do to say healthy? And if I need to go back on medications, what are my options? What are the safest medications?"

Non-medication treatment. A woman who opts to go off antidepressants during pregnancy could try psychotherapy or another non-drug treatment. If so, she should be seen more frequently by her therapist during pregnancy, Brown says, to determine how well she's doing and to monitor her for depression relapse.

Gradually coming off drugs. If you choose to come off antidepressants during pregnancy, discuss this with your doctor. "You have to taper off these drugs gradually," Brown says. "You can't just stop them."

Postpartum depression. If you had postpartum depression following a previous pregnancy, that's another decision factor. For women who've had many episodes and been quite ill, Nonacs says she'd advise staying on the medication. Other women might try coming off antidepressants during pregnancy and restarting after delivery.

Some Reassurance

A July 2015 study in BMJ, with a co-author from the Centers for Disease Control and Prevention's National Center on Birth Defects and Developmental Disabilities, looked at nearly 18,000 mothers of infants with birth defects and about 9,850 mothers of infants without. The study found "reassuring" evidence for some SSRIs during pregnancy, notably Zoloft, Celexa and Lexapro, with no association with birth defects. However, results suggested birth defects occurred more frequently among women treated with Paxil or Prozac early in pregnancy. The study only found an association, not cause and effect, and risks were still small, researchers noted.

Other studies give additional perspective:

-- An April 2015 study in BMJ looked at 2.3 million live births in five Nordic nations to determine the risk of birth defects of infants whose mothers had used SSRI drugs or the antidepressant venlafaxine (Effexor) in early pregnancy. There was no increase in overall cardiac birth defects among infants exposed to these antidepressants.

-- A December 2013 study in the New England Journal of Medicine that looked at all the single live births (more than 600,000) in Denmark over a decade, did not detect a significant association between SSRI use in pregnant women and autism spectrum disorder in children. However, the authors found enough possibility of increased risk to conclude "the association warrants further study."

-- A November 2013 study in Clinical Epidemiology looked at overall antidepressant use in the same Danish population. It found no significant association with autism once researchers accounted for other risk factors such as psychiatric illness of the mother or exposure to other medications in pregnancy.

-- A November 2012 study in the American Journal of Psychiatry looked at 240 pregnant women in Toronto. Women with depression either took SSRIs or Effexor, or had stopped taking antidepressants before pregnancy. Pregnant women without depression were also included. Of their children, evaluated at 3 and 7 years old, those whose mothers were treated with antidepressants, or who had no history of depression, had fewer behavioral problems than children born to mothers with untreated depression.

The MGH Center for Women's Mental Health's website offers an excellent resource for women weighing the risks of drug treatment for mental health disorders during pregnancy.

Lisa Esposito is a Patient Advice reporter at U.S. News. You can follow her on Twitter, connect with her on LinkedIn or email her at lesposito@usnews.com.