Selective Serotonin Reuptake Inhibitors (SSRIs) like Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil, Pexeva) and Sertraline (Zoloft) are commonly used in depression during pregnancy. Despite this fact, they are not risk-free medications.
Antidepressants in pregnancy have been extensively studied with contradictory results. The absolute true is not available, but there are some facts healthcare professionals know for sure:
- Depression is no a temporary condition that will go away without intervention
- Untreated depression in pregnancy has severe consequences for the mother and the baby
- Sometimes, depression may need pharmacologic intervention and you and your prescriber will determine what is the best course of action
- You should talk to your doctor before discontinuing any treatment, including antidepressants during pregnancy.
It is not a simple decision to determine what is best for you and your baby. Making this sort of decision involves weighing the risks of untreated depression in the mother against the potential risks of antidepressant exposure to the fetus.
Depression
Depression is a serious medical illness. It is possible that pregnancy could trigger the development of depression or cause a relapse in previously depressed patients. In fact, research has shown that 15% of women suffer depression during pregnancy, Treatment for depression usually includes counselling/psychotherapy and/or medications.
Effects of Untreated Depression during pregnancy
Ignoring symptoms and treatment for depression has many negative consequences for you and your baby.
- you are more likely to smoke, drink alcohol and use illicit drugs
- you are more likely to experience preeclampsia, a life threatening condition
- your eating and sleeping patterns can be affected in a negative way
- you are more likely to experience other pregnancy complications
- your baby is at risk of being premature and underweight
- your baby’s brain can be permanently altered, if you don’t treat your depression
- your baby will be more prompt to anxiety & depression in its adulthood
One of the most serious effects of not treating depression during pregnancy is the increased risk for postpartum depression (depression following childbirth). It is well documented that postpartum depression may interfere with a woman’s ability to take care of and bond with her baby. This may have a negative effect on the baby’s development and behavior.
Antidepressants used to treat depression in general
• Selective serotonin reuptake inhibitors (SSRIs) include fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro) and fluvoxamine(Luvox)
• Serotonin and norepinephrine reuptake inhibitors (SNRIs). include duloxetine (Cymbalta), venlafaxine (Effexor XR), desvenlafaxine (Pristiq, Khedezla) and levomilnacipran (Fetzima).
• Atypical antidepressants. They include trazodone, mirtazapine (Remeron), vortioxetine (Trintellix), vilazodone (Viibryd), bupropion (Wellbutrin, Aplenzin, Forfivo XL) and Nefazodone(Serzone)
• Tricyclic antidepressants. such as imipramine (Tofranil), nortriptyline (Pamelor), amitriptyline(Elavil, Vanatrip), doxepin(Sinequan) and desipramine (Norpramin)
• Monoamine oxidase inhibitors (MAOIs). MAOIs — such as tranylcypromine (Parnate), phenelzine (Nardil) and isocarboxazid (Marplan), moclobemide(Manerix)
Treatment of depression in pregnancy
You and your doctor will determine how to treat your depression based on: your personal preferences, the severity of your symptoms, whether symptoms have returned in the past if you have ever gone off medicines, and how quickly you respond when you restart medicines.
If the appropriate decision is to stop your antidepressant, you will be recommended a gradual reduction in dose. Abrupt stopping could cause more harm than good. So, that your body get use to be without the medication.
SSRI’s in Pregnancy
SSRI’s are the most commonly used antidepressants in pregnancy. Regardless, other antidepressants have been successfully used too.
Before the extended use of SSRIs, tricyclic antidepressants were widely utilized in pregnancy.Desipramine and nortriptyline are the preferred tricyclic antidepressants for use in pregnancy, as they are less likely to increase postural hypertension and constipation, which are common issues in pregnancy.
SSRI’s
These group of medications is not risk free. However, studies have not been associated with an increase in birth defects:
Fluoxetine (Prozac® & Sarafem®) https://mothertobaby.org/fact-sheets/depression-pregnancy/
Paroxetine (Paxil®) https://mothertobaby.org/fact-sheets/paroxetine-paxil-pregnancy/
Sertraline (Zoloft®) https://mothertobaby.org/fact-sheets/sertraline-zoloft-pregnancy/
Citalopram (Celexa®) & Escitalopram (Lexapro®) https://mothertobaby.org/fact-sheets/citalopramescitalopram-celexalexapro-pregnancy/
It seems citalopram might cross the placenta in lower amounts than some of the other SSRI medications.
Escitalopram has not being extensively studied because is one of the two medical substances in citalopram.
Fluvoxamine (Luvox®) http://www.bcmj.org/article/use-antidepressants-pregnancy-and-lactation
Herbal antidepressant
St. John’s Wort (Hypericum perforatum)https://mothertobaby.org/fact-sheets/st-johns-wort/
St. John’s Wort is an herbal medication most commonly used to treat mild or moderate depression.
A small study did not find an increase in birth defects compared to women taking prescription antidepressant medication.
St. John’s Wort causes increased uterine muscle tone in laboratory animals, and could potentially cause uterine contractions.
SNRIs
Venlafaxine (Effexor®) https://mothertobaby.org/fact-sheets/venlafaxine-effexor-pregnancy/
Two studies have looked specifically at the use of venlafaxine in pregnancy; neither found an increased risk of congenital anomalies.
If a woman develops preeclampsia during pregnancy, venlafaxine should be tapered and/or discontinued.
Duloxetine (Cymbalta®) https://mothertobaby.org/fact-sheets/duloxetine/
Studies suggest that using duloxetine during pregnancy is unlikely to increase the chance to have a baby with a birth defect.
Atypical antidepressants
Mirtazapine (Remeron®) https://mothertobaby.org/fact-sheets/mirtazapine-remeron-pregnancy/
A study of mirtazapine use in pregnancy demonstrated no increased risk of major malformations.
Mirtazapine may be beneficial in some patients with nausea & vomiting in pregnancy. Unfortunately, weight gain with mirtazapine can increase obstetrical complications, including gestational diabetes. Additionally, mirtazapine’s propensity to induce sedation may be more difficult to tolerate in pregnancy.
Trazodone (Desyrel®) https://mothertobaby.org/fact-sheets/trazodone/
Three small studies did not find an increase in the chance of birth defects.
Nefazodone (Serzone®) https://mothertobaby.org/fact-sheets/nefazodone/
Buproprion (Wellbutrin®) https://mothertobaby.org/fact-sheets/bupropion-wellbutrin-pregnancy/
Bupropion has been relatively well-studied in pregnancy, in part, thanks to the manufacturer’s pregnancy registry. An increased risk of major malformations has not been identified.
Interventions that could improve depression during pregnancy
– Providing a patient with education on the topic of depression and the postpartum period is paramount.
– Exercise: Physical exercise during pregnancy is associated with improved cardiorespiratory fitness and other health benefits, without evidence of harm to the newborn.It is not a stand-alone treatment for depression, however, exercise has been shown to help alleviate symptoms of major depression in nonpregnant samples.
– Electroconvulsive therapy (ECT) is an established therapeutic modality for severe, catatonic, or psychotic depression, where rapid antidepressive effects are urgently required and lag time to therapeutic benefit associated with pharmacotherapy may be unacceptable.
– Psychotherapy (eg, psychodynamic, cognitive-behavioral) should be offered if the patient is able to engage in a psychotherapeutic relationship.
– Cognitive-behavioral therapy, supportive psychotherapy, and conjoint therapy (with the partner) are excellent options in this population.
– Other nonmedicinal interventions include improvement in nutrition and diet; elimination of caffeine, nicotine, and alcohol; and facilitation of proper sleep hygiene. Reduction of stressors, as well as provision of information on relaxation techniques, can also be useful. Some will benefit from referral to local support groups for women who struggle with depression during pregnancy and the postpartum period. Additionally, bright light therapy may be beneficial to those women who have a seasonal component to their affective illness.
Factors that could contribute to the development of depression in pregnancy include
– insufficient social support
– living alone
– marital discord
– having an unwanted pregnancy
– or having multiple children
– Age: up to 26% of pregnant adolescents develop major depression
– personal or family history of affective illness also predisposes to depression during pregnancy
Further, if a woman discontinues her antidepressant medication at the time of conception, she has a much higher chance of redeveloping depressive symptoms during her pregnancy than if she were to remain on an antidepressant throughout her pregnancy.
If a woman has chosen to utilize an antidepressant medication throughout pregnancy, it is typically recommended that she continue it postpartum. The postpartum period is a time of increased risk of affective illness; therefore, continuation of an antidepressant medication may be beneficial in maintenance of euthymia.
Risks of using SSRIs & other antidepressants during pregnancy
Risk of Congenital Malformations: use of paroxetine could be related to cardiac septal defects, but not all, studies have also shown an elevated risk of cardiac defects in children with prenatal exposure to other SSRIs.
Risk of Adverse Pregnancy Outcomes: use of antidepressants could be associated to preterm delivery, low birth weight, and lower Apgar scores. The observed effects were small: about 3 days shorter gestational age, 75 g lower birth weight, and less than half a point on the 1- and 5-minute Apgar scores. In fact, these values typically fall within the normal range.
Risk of Neonatal Symptoms: about 25% of babies exposed to antidepressants late in pregnancy commonly reported symptoms in newborns include tremor, restlessness, increased muscle tone, and increased crying. Reassuringly, these syndromes appear to be relatively benign and short-lived, resolving within 1 to 4 days after birth without any specific medical intervention.
Another risk at birth is about use of a SSRI antidepressants after the 20th week of gestation. It may be associated with a higher than expected number of cases of persistent pulmonary hypertension of the newborn. Some studies have shown very high risk, while others showed a much lower risk than the 1% originally reported.
Risk of Developmental Delays:
One study showed that prolonged use of an SSRI during pregnancy was associated with lower language competence in children at age three. Another study in 10-month babies exposed via materna to SSRIs, showed exposed babies scored lower on gross motor, social-emotional and adaptive behavior subscales of the Bayley Scales of Infant Development (BSID-III).
A large study in preschool children did not indicated significant differences in IQ, temperament, behavior, reactivity, mood, distractibility, or activity level between exposed and non-exposed children. The same large group was reassessed 5 years after, with similar results.
Risk of Autism: Two studies linked use of SSRIs & autism. One important limitation of these two studies is that parental psychiatric disorder in itself is associated with an increased risk of Autism spectrum disorder (ASD) in the offspring, and these studies could not distinguish between the effects of drug exposure and the consequences of the underlying maternal psychiatric illness.
Two other studies, however, suggest that the association between prenatal antidepressant exposure and ASD in the offspring observed in previous studies may, all or in part, be the result of confounding factors, specifically the underlying indication for antidepressant use or other unmeasured factors related to maternal illness during pregnancy. Researchers also observed that the risk of having a child with autism spectrum disorder was also elevated among women who received SSRIs before – but not during — pregnancy, further supporting the notion that other environmental or genetic factors – as opposed to antidepressant exposure – may modulate risk for autism.
Undoubtedly all women, if given the choice, would prefer to avoid taking any medications during pregnancy. Many women, unfortunately, suffer from depression during pregnancy and deferring treatment with antidepressants may not be the best option for them. No clinical decision, particularly one of this complexity, is risk free or perfect. However, we do have considerable data to indicate that many antidepressants, especially the SSRIs, may be used during pregnancy.