Using Antidepressants During Pregnancy - How Common And For What Reasons?

Main Category: Depression
Also Included In: Pregnancy / Obstetrics
Article Date: 16 Aug 2007 - 1:00 PDT

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A new study in BJOG: An International Journal of Obstetrics and Gynaecology examines the prevalence of antidepressant use before, during and after pregnancy and identifies the factors for their use. It is also the first study of its kind to determine the types and dosage of antidepressants prescribed to pregnant women.

97,680 pregnant women from the province of Quebec in Canada between the ages of 15 and 45 were studied between 1998 and 2002. The women were all covered by free universal health care offered by the government of Quebec.

Findings show that the use of antidepressants in women declined throughout pregnancy. Prevalence of their use during the first trimester fell the highest and continued to fall in the later stages (only 3.7% of women used antidepressants in the first stage of pregnancy). Use of antidepressants among women increased after childbirth to 7%. Researchers note that the reasons for the fall in use are probably because doctors are cautious about prescribing antidepressants during pregnancy and/or women are themselves careful about using antidepressants when pregnant. These trends could be the result of recent studies highlighting the possible effects of antidepressants on the fetus which include cardiac malformations and persistent pulmonary hypertension in newborns. This is counter-balanced by the knowledge that discontinuation of antidepressant use by mothers already suffering from clinical depression is linked to depression relapse, withdrawal and maternal stress. Researchers advise that further research is required into assessing the impact of not treating depressive symptoms and the consequences to the mother and newborn. Likewise, there is also a need to understand the use of herbal remedies such as St John's Wort as alternatives to antidepressants during pregnancy.

Researchers found that the most common form of antidepressants used were: selective serotonin reuptake inhibitors (SSRIs), followed by serotonin and norepinephrine reuptake inhibitors (SNRIs) and tricyclics. Paroxetine and sertraline were the most frequently used SSRIs while venlafaxine and amitriptyline were the most commonly used SNRI and tricyclic respectively. The use of nonhydrazine reversible monoamine oxadase inhibitors (MAOIs) was found to be minimal because of the safety concerns over drug and food interactions. Researchers observed that SSRIs were widely used because of their established efficacy and safety.

The research team found that antidepressant prescription during pregnancy followed existing guidelines and recommendations 92.3% of the time and were never prescribed over the recommended dosage. However, the researchers added that the changes in maternal physiology experienced during pregnancy mean that higher doses of most antidepressants may be needed. Only 6.1% of women switched antidepressants while the majority of pregnant women discontinued use. The researchers suggest that for women who want to carry on with antidepressants, careful treatment planning is required.

The research also revealed that factors associated with higher antidepressant use include older maternal age, being on welfare, having current prescriptions for other types of medication (other than antidepressants) and having had more visits to the physician, and at least one diagnosis of depression a year before becoming pregnant. Researchers deduce a link between health levels with socio-economic status in determining the incidence of depression among pregnant women.

Associate Professor Anick Bérard, from the University of Montreal, who led the study said "While there has been an increase in the rate of diagnosed depression during pregnancy over the years, the fear of treating depressed pregnant women with antidepressants remains. Given the latest evidence-based data on the subject, I do not foresee a change in the situation anytime soon. Indeed, in another study, our team also found that gestational exposure to paroxetine was associated with congenital cardiac malformations and others have found the same."

"Lately, SSRIs have been linked with adverse pregnancy outcomes. However, I do agree that not treating depression during pregnancy could harm the baby either on a physical or psychosocial basis. Therefore, given the condition of the mother, the treating physician and the mother should carefully evaluate the risks and benefits, and come up with a scenario where the benefits outweigh the risks - this is not an easy task. Nevertheless, for the majority of women, I believe that antidepressants should not be discontinued.'

Professor Philip Steer, BJOG editor-in-chief said "The recommendation to use antidepressants during pregnancy needs to be carefully considered by doctors and in some cases, by a group of specialists so that all aspects of care can be planned together."

"At present, doctors are hesitant to prescribe antidepressants due to the effects they may have on the fetus, while mothers avoid using them for similar reasons."

"Women should have full information on the potential for adverse outcomes to them and their baby should they decide to carry on with antidepressant use, alongside the side effects that will occur if they come off the medication. The decision to stop using antidepressants should be carefully weighed against the severity of their depression."

In a commentary piece to accompany the Ramos et al BJOG paper, O'Keane and Marsh discuss the incidence of maternal depression with reference to current research. They note that rates of depression tend to be higher in women during the childbearing years, with as many as 25% of women in some countries being diagnosed with depression during pregnancy, with a 13 - 15% rate of postnatal depression. Around 50% of postnatal depression started during pregnancy, and severe depression is associated with poorer long-term developmental outcomes in babies. Adverse effects can persist into childhood, and even into adulthood.

O'Keane and Marsh's commentary mentions the effects of psychosocial stress and mild depression on birth outcomes and notes that life events are individual and unpredictable (the common obstetric outcomes gathered from epidemiological studies being preterm delivery and/or low birth weight). Therefore, the authors note that pregnant women with depression should be assessed and treated on a case-by-case basis. They also suggest that the finding of reduced prescribing during pregnancy by Ramos et al is of concern, since it points to depression being seriously under-treated during these stressful months. They hypothesise a link between prenatal programming of the adreno-cortical axis (which controls the response to stress in later life) and the subsequent development of depression at any time from adolescence to old age.

BJOG: An International Journal of Obstetrics and Gynaecology is owned by the Royal College of Obstetricians and Gynaecologists (RCOG) but is editorially independent and published monthly by Blackwell Publishing. The journal features original, peer-reviewed, high-quality medical research in all areas of obstetrics and gynaecology worldwide. Please quote 'BJOG' or 'BJOG: An International Journal of Obstetrics and Gynaecology' when referring to the journal. .

References

-- É Ramos, D Oraichi, É Rey, L Blais, A Bérard. Prevalence and predictors of antidepressant use in a cohort of pregnant women. BJOG: An International Journal of Obstetrics and Gynaecology (OnlineEarly Articles); doi:10.1111/j.1471-0528.2007.01387.x

-- O'Keane v and Marsh M. Antidepressant prescribing and pregnancy: comment on 'Prevalence and predictors of antidepressant use in a cohort of pregnant women' by Ramos et al. BJOG 2007; 114. 1051-1054.

http://www.rcog.org.uk