Women who take a popular class of antidepressants during pregnancy may be risking the health of their developing fetus, and the risk may outweigh any benefit to the mother, a new review of data suggests.
According to new research, use of selective serotonin reuptake inhibitors (SSRIs) — which include Celexa, Paxil, Prozac, and Zoloft — while pregnant can increase the risk of miscarriage, preterm birth, pregnancy complications such as preeclampsia and neurobehavioral problems such as autism later in life.
"There is clear and concerning evidence of risk when pregnant women use these medications," said Dr. Adam Urato, senior author of a study appearing in the online edition of Human Reproduction.
On the other hand, he said, there is no clear evidence that SSRI antidepressants actually benefit the mother in terms of alleviating mild-to-moderate depression.
Not everyone agreed with the researchers' conclusions, however. Dr. Beatriz Currier is associate professor of psychiatry and behavioral sciences at the University of Miami Miller School of Medicine.
She said there is no blanket recommendation as to how best to treat depression during pregnancy and "every woman who presents to a clinician has to undergo a case-by-case analysis of the benefits and risks of antidepressant therapy."
Currier also said that there is "no conclusive data about an increased risk of miscarriage being associated with antidepressants." Nor is there any reason to conclude the rate of preeclampsia or birth defects is higher, she said, although there is some evidence that antidepressant use may be associated with low birth weight babies.
According to background information in the study, antidepressants are the most widely prescribed medications among adults aged 18 to 44. Up to 13 percent of pregnant women take an antidepressant. Many of these may be women undergoing treatment for infertility, a condition which is often accompanied by depression.
In 2010, up to almost 7,000 babies conceived by in vitro fertilization (IVF) may have been exposed to an antidepressant, the study authors said.
In their research, Urato and his team looked at the existing literature on women who had fertility problems and were also taking SSRIs. They say they found a number of concerns.
First of all, some studies suggest that SSRIs may actually undermine women's efforts to get pregnant, the researchers said. And for those who do get pregnant, the drugs may increase the risk for miscarriage as well as congenital problems in their children. The most striking association was for use of Paxil (paroxetine) during pregnancy and the risk for congenital heart defects, they said.
The study authors noted that, in 2005, the U.S. Food and Drug Administration requested that Paxil's maker, GlaxoSmithKline, change Paxil's pregnancy category from a "C" to a "D" rating, indicating that it poses a risk to the fetus.
The authors also pointed to a 2011 study from Kaiser Permanente Medical Care Program of Northern California that found a "twofold increased risk of autism spectrum disorders associated with maternal treatment with SSRI antidepressants during the pregnancy, with the strongest effect associated with treatment during the first trimester."
On the other hand, isn't untreated depression in a mother-to-be a hazard for both mother and fetus? According to Currier, sometimes SSRIs remain the best option for women facing this situation.
"Generally speaking, for women with very mild depression, the first course of treatment is that of cognitive behavioral therapy or other non-pharmacological [forms] of treatment," she said. "But in many cases, patients with moderate and severe depression will, in fact, require antidepressant therapy in order to treat their comorbid psychiatric illness, which cannot be ignored or dismissed," Currier added.
However, Urato said that an increasing number of studies are finding that SSRIs have little clinical benefit for mild-to-moderate depression when compared with a placebo (inactive) pill.
Other alternatives may exist for women who are battling depression, added study lead author Alice Domar, executive director of the Domar Center for Mind/Body Health at Boston IVF. The center is described on its Web page as focused on "enhancing the mind/body connection" through interventions such as "acupuncture, psychology, nutrition and restorative yoga."
According to Domar, cognitive behavioral therapy, in which patients learn how to direct their thinking and behavior to more constructive ends, probably has the most evidence behind it.
Exercise also has demonstrated efficacy, and yoga may have some benefit, she added.
"What I don't want to do is scare the heck out of women who are pregnant and have severe depression," Domar said. "I'm not suggesting that someone who is suicidal stop taking antidepressants cold turkey.
You have to look at the individual risk-benefit ratio. In that case [suicidality], the risk of harm to her and her baby is far higher than the risk posed by an SSRI. For those with mild or moderate depression, the ratio shifts the other direction," she noted.
And, Urato added, "We're not saying women should not take SSRIs. The goal is to give them information so they can make the right decision for them."