Update January 20, 2016
I’m with you. None of us wants to have to take a medication while we’re pregnant. We’re trying to protect our babies from potential toxins. We go organic to avoid unnecessary chemicals in our foods, we switch to glass water bottles to avoid BPA, we stop drinking wine and coffee. So the last thing we want is to purposefully expose our babies to possibly unsafe medications!
But untreated depression in pregnancy can also be harmful – leading to a host of short and long term problems for mom and baby. This leaves pregnant mommas struggling with a really tough decision.
It’s a rock and a hard place kind of choice.
So what’s a pregnant mom to do?
Are Antidepressants Safe or Dangerous During Pregnancy?
Emerging data on many medications used in pregnancy, from tylenol to antidepressants suggests that we must continue to deeply question whether most are safe for use in pregnancy. All medications used for mental health cross the placenta, thus exposing the developing fetus to these drugs, and, in spite of widespread use, there’s still a lot we don’t know about their safety in pregnancy. Yet another recent study showed that paroxetine (Paxil), a widely used antidepressant in pregnancy, increases the risk of birth defects. While the risk is small, if this happens to your baby, that risk is 100% for you.
The most commonly recommended medications for depression (and anxiety) in pregnancy are the SSRIs and SNRIs, and these are really the only ones that are considered even remotely “safe.” Most other categories of antidepressants – mood stabilizers and tricyclic antidepressants, for example, are associated with congenital malformations and should almost always be avoided.
While substantial studies in hundreds of thousands of pregnant women do not show any harm from using these drugs while pregnant, other important studies, including by the National Birth Defects Prevention Study, have found that exposure during pregnancy increases the risks of complications including:
- Congenital malformations (septal heart defects, craniosyntosis, anencephaly, and omphalocele)
- Preterm birth
- Gestational hypertension
There is a controversial association with increased miscarriage risk. Additionally, newborns that had been exposed to maternal use of antidepressants during the pregnancy, may exhibit poor neonatal adaptation (neonatal behavior syndrome), which includes tremors, rapid breathing, and even persistent pulmonary hypertension.
Since 2004, drug-labeling laws require a warning about the potential for adverse effects on newborns to appear on antidepressant packaging.
Timing of use during the pregnancy (i.e., which trimester), and at what dose, may have an impact on safety, as does the choice of medication.
Are There Safe, Effective Non-Drug Options?
Effective non-drug options in pregnancy include omega-3 fatty acids, light therapy, Sam-E, yoga, and talk therapies. For more information see Depression in Pregnancy: 10 Ways to Beat the Blues Without Medication.
Should I Take a Medication? 3 Steps to an Easier Decision
Should you take an antidepressant or not? Take this quick quiz to help you answer this question.
YES NO I have severe depression, frequent relapses, or just feel I can’t cope with trying natural approaches or waiting to see if they work.
YES NO I’ve tried the natural therapies in Depression in Pregnancy: 10 Ways to Beat the Blues Without Medication and they just don’t work for me.
YES NO I feel more confident in the effectiveness or safety of medications than in natural therapies.
YES NO I understand that there is a risk to taking these drugs in pregnancy, including the risk of my baby having a heart defect, and I can accept that risk.
If you answered YES to any of the above statements, then an antidepressant might be the best choice for you at this time. If you answered no to all of these questions, are not having thoughts of self-harm, and have a solid support network, then it might be appropriate to try non-pharmacologic methods first.
Reducing Your Baby’s Risks from Antidepressant Exposure During Pregnancy
I am sure that if you have decided you need to use an antidepressant, this was not easy. Trust that you are making the best choice at this time for you and your baby. To reduce the risks of antidepressant exposure for you and baby:
- Choose a medication that is known to result in the lowest fetal/neonatal exposure whenever possible. Prozac (fluoxetine) is the best-studied medication with the highest safety profile, however, it has a tendency to accumulate in the breastfeeding baby, thus in spite of controversy over potentially being able to cause congenital defects (teratogenicity), Zoloft (sertraline) is typically the first line medication recommended during pregnancy.
- Avoid the use of newly released antidepressant medications while pregnant – use only those that have been time-tested in pregnant women.
- Use the lowest effective dose in the first trimester, increasing in the second and third trimesters, as needed to maintain symptom control.
- If you are pregnant and wish to try to lower your dose, do so by tapering down by 10% each week to minimize the potential for relapse, remaining at the lowest possible dose at which your symptoms stay well controlled.
- Add in non-supplement, non-pharmacologic treatments such as light therapy, yoga, and cognitive behavioral therapy, all of which have been found to be effective and do not interfere with your medication, but might allow you to effectively lower your dose.
What if I’m Already on a Medication?
If you got pregnant while already on an antidepressant, set up a time to discuss the risks of that medication on your pregnancy with your midwife or OB. Work with your care provider to switch you to the safest possible medication that will work for you, and at the appropriate dose.
If you are already on a medication that is preferred for safety in pregnancy, at a dose that is really doing the job for you, and you are past the first trimester, then sometimes the best thing may actually be to stay at that dose because sometimes lowering the dose just leads to rebound symptoms that are hard to control at a lower dose.
These really are tough decisions. While a non-pharmacologic approach whenever possible may be the ideal, keeping yourself in a healthy mental space is also essential for a healthy pregnancy and transition to motherhood feeling prepared and happy to meet and care for your new baby.
Benard, A. et al. The risk of major cardiac malformations associated with paroxetine use during the first trimester of pregnancy: A systematic review and meta-analysis. British Journal of Clinical Pharmacology.doi: 10.1111/bcp.12849.
Hogg K, Price EM, et al. (2012). Prenatal and perinatal environmental influences on the human fetal and placental epigenome. Clin Pharmacol Ther, 92(6):716-26.
Misri, S and S Lusskin. (2013). Depression in pregnant women: Management. http://www.uptodate.com/contents/depression-in-pregnant-women-management?source=see_link
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