August 21st, 2009 
Women who are depressed during pregnancy can take hope that antidepressants and/or “talk therapy” may be safe and appropriate treatment options, according to new professional guidelines made public this week.
“Depression in pregnant women often goes unrecognized and untreated in part because of concerns about the safety of treating women during pregnancy,” lead author of the guidelines, Dr. Kimberly Ann Yonkers, from Yale University, New Haven, Connecticut, said in a statement.
The guidelines on depression in pregnancy, which are based on an extensive review of prior research, were issued by the American Psychiatric Association and the American College of Obstetricians and Gynecologists.
There are both pros and cons to using antidepressants during pregnancy, the report states. The drugs can effectively treat mom’s depression, which has been linked to problems in the newborn. However, there is also evidence tying them to birth defects and reduced birth weight.
Psychotherapy may be a suitable alternative to antidepressants for some women with mild-to-moderate depression, the report indicates.
According to the report, women thinking about becoming pregnant may possibly taper or discontinue their antidepressants if they have had mild or no symptoms for 6 months or longer.
However, they may need to continue their medications if they have a history of severe, recurrent depression or other major psychiatric illness.
The guidelines suggest that women see a psychiatrist for aggressive treatment if suicidal or acute psychotic symptoms are present.
Pregnant women currently taking antidepressants may be able to remain on the medications if they discuss the pros and cons with their doctors, the guidelines state.
Depending on their mental health history, these women may attempt tapering and going off their medications if symptom-free. Pregnant women taking antidepressants may benefit from psychotherapy if symptoms are still apparent, according to the document.
Pregnant women not currently taking antidepressants may consider psychotherapy as alternative to antidepressants, the report indicates.
Related
- Drugs for depression, anxiety tied to preterm birth
Pregnant women who take certain drugs for depression or anxiety may have heightened risks of preterm delivery or other birth complications, according to a new study.
Researchers found that among nearly 3,000 women who gave birth in Washington State, those who started taking antidepressants known as selective serotonin reuptake inhibitors (SSRIs) in the second or third trimester had a higher risk of preterm birth.
Compared with their counterparts not on the medications, these women were nearly five times more likely to deliver prematurely.
The same risk was not seen, however, among women who started on an SSRI before pregnancy or during the first trimester. SSRIs include drugs like sertraline (Zoloft), paroxetine (Paxil) and fluoxetine (Prozac).
The researchers also found a higher risk of preterm delivery among women who took anti-anxiety drugs known as benzodiazepines, regardless of when they began treatment.
Those drugs, which include medications like lorazepam (Ativan) and alprazolam (Xanax), were linked to higher risks of other complications as well – including low birth weight, newborn respiratory distress and a low Apgar score, a standard measure of newborn health.
The findings of the study are published in the American Journal of Obstetrics & Gynecology.
Exactly what the study means for women on SSRIs or benzodiazepines is not entirely clear. A major limitation is that it could not estimate the benefits of treatment, lead researcher Dr. Ronit Calderon-Margalit, of the Hebrew University-Hadassah School of Public Health in Jerusalem, noted in an email to Reuters Health.
Any risks of using the medications during pregnancy need to be balanced against the risks of leaving depression and anxiety disorders untreated.
“It is very important to have other studies of the risks associated with (these) drugs, but also of benefits associated with treating mothers,” said Calderon-Margalit, who was at the University of Washington in Seattle at the time of the study.
In addition, SSRIs did not appear to present equal risks for all women. Calderon-Margalit described the antidepressant findings as “mostly reassuring” for women who start the drugs before pregnancy or in the first trimester — as most SSRI users in the study had.
The study included 2,793 pregnant women, 11 percent of whom used a psychiatric medication during pregnancy. Of these, 138 were on an SSRI, while 85 used a benzodiazepine.
Among women who were not on any medication, 9 percent gave birth prematurely, versus nearly half of women on benzodiazepines.
Meanwhile, 14 percent of women on SSRIs had a preterm birth, but the elevated risk turned out to be concentrated among those who started an antidepressant after the first trimester. Of those 21 women, 16 delivered prematurely.
Several other birth complications, often related to preterm birth, were also higher-than-average among women on benzodiazepines.
Seventeen percent of their newborns suffered respiratory distress syndrome and one-third ended up in the neonatal intensive care unit. Those figures were 3 percent and 6 percent, respectively, among newborns whose mothers had not used psychiatric medications during pregnancy.
Calderon-Margalit pointed out that most women on benzodiazepines used lorazepam (Ativan), so it is possible that the risks are associated mainly with that drug. However, further research is needed to determine whether any particular medications carry particular risks.
- Antidepressant tied to risk of newborn heart defect
Women who use the antidepressant bupropion during early pregnancy may have an increased risk of having a baby with a particular type of heart defect, a new study suggests.
Researchers caution that it is not clear whether the medication, marketed as Wellbutrin, is the cause. And even if it is, they say, the absolute risk of the heart defect would be small — affecting just 2 out of every 1,000 infants born to women who used bupropion during the first trimester.
But the findings, published in the American Journal of Obstetrics & Gynecology, do add to questions about the risks of using antidepressants during early pregnancy.
Some studies have already linked other antidepressants — including some of the commonly used selective serotonin reuptake inhibitors (SSRIs) — to higher-than-average, though small, risks of certain birth defects.
A study last year, for example, found that among nearly half a million Danish children born between 1996 and 2003, the risk of heart defects was elevated among those whose mothers had used SSRIs such as fluoxetine (Prozac), sertraline (Zoloft) and citalopram (Celexa) during early pregnancy.
In this latest study, researchers found that among more than 12,700 U.S. infants born between 1997 and 2004, those whose mothers used bupropion during early pregnancy had more than double the risk of heart defects known as left outflow tract defects, compared with infants whose mothers had not used the drug.
Left outflow defects affect the flow of blood from the heart’s left chambers to the rest of the body. In this study, the most common type of this defect was coarctation of the aorta — a narrowing in the body’s main artery that, in children, typically requires surgical repair.
The findings do not mean, however, that depressed women on bupropion should stop taking it if they are planning a pregnancy, according to the researchers.
“I think it’s important that women understand that they should not just stop taking their medication,” said Dr. Jennita Reefhuis, a senior epidemiologist at the U.S. Centers for Disease Control and Prevention and one of the researchers on the study.
Instead, she told Reuters Health, women should talk with their doctors, ideally when they are planning a pregnancy rather than after they conceive.
The potential risk of birth defects from using antidepressants must be weighed against the risks of a woman stopping her current depression therapy, Reefhuis said.
“This study needs to be replicated before we can say anything conclusive,” Reefhuis said, noting that the findings point to an association between bupropion and left outflow defects, but cannot by itself prove cause-and-effect.
If the association is causal, she said, the absolute risk to any one woman would be small. For every 1,000 births, there are an estimated 0.8 cases of left outflow tract heart defects; based on the current findings, that rate would be 2 per 1,000 among women who use bupropion in the first trimester.
Reefhuis also pointed out that with any pregnancy, the overall risk of having a baby with some form of birth defect is 3 percent.
Guidelines released last year by the American Psychiatric Association and the American College of Obstetricians and Gynecologists state that psychotherapy may be an effective alternative to antidepressants for pregnant women with mild to moderate depression.
However, the guidelines say, women with a history of more severe depression, or other major psychiatric disorders, may need to continue with their medication.
Bupropion is also prescribed for smoking cessation, under the brand-name Zyban. In the case of smoking cessation, Reefhuis said, it may be easier for women to find an effective alternative to the drug.
- Acupuncture Found Effective Against Depression During Pregnancy
In a study to be presented February 4 at the Society for Maternal-Fetal Medicine’s (SMFM) annual meeting, The Pregnancy Meeting ™, in Chicago, researchers will unveil findings that show that acupuncture may be an effective treatment for depression during pregnancy.
“Depression during pregnancy is an issue of concern because it has negative effects on both the mother and the baby as well as the rest of the family,” said Dr. Schnyer, one of the study’s authors.
About 10% of pregnant women meet criteria for major depression and almost 20% have increased symptoms of depression during pregnancy. The rates of depression in pregnant women are comparable to rates seen among similarly aged non-pregnant women and among women during the postpartum period, but there are far fewer treatment studies of depression during pregnancy than during the postpartum period.
Dealing with depression is difficult for pregnant women because the use of anti-depressants poses concerns to the developing fetus and women are reluctant to take medications during pregnancy.
In the study, an evaluator-blinded randomized trial, 150 participants who met the Diagnostic & Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for Major Depressive Disorder were randomized to receive either acupuncture specific for depression (SPEC, n=52) or one of two active controls: control acupuncture (CTRL, n=49) or massage (MSSG, n=49). Treatments lasted eight weeks (12 sessions). Junior acupuncturists masked to treatment assignment needled participants at points prescribed by senior acupuncturists. Massage therapists and patients were not blinded. The primary outcome was the Hamilton Rating Scale for Depression, administered by blinded raters at baseline and after four and eight weeks of treatment. Data were analyzed using mixed effects models and by intent-to-treat.
The results showed that the women who received SPEC experienced a significantly greater decrease in depression severity compared to the combined controls or CTRL acupuncture alone. They also had a higher response rate (63.0%) than the combined controls or CTRL acupuncture alone. Symptom reduction and response rates did not differ significantly between controls (CTRL 37.5% and MSSG 50.0%). Mild and transient side effects were reported by 43/150 participants (4 in MSSG; 19 in CTRL, 20 in SPEC). Significantly fewer participants reported side-effects in MSSG than the two acupuncture groups.
“The results of our study show that the acupuncture protocol we tested could be a viable treatment option for depression during pregnancy” said Dr. Schnyer.
- Stress, Anxiety Can Up Risk of Depression in Pregnancy
Stress, history of depression, lack of social support and unintended pregnancy are among the major factors that contribute to increased risk of depression in pregnant women, a new study shows.
Other important factors are maternal anxiety, domestic violence and having public insurance coverage, said the University of Michigan researchers, who reviewed 159 studies conducted between 1980 and 2008.
The study appears in the January issue of the American Journal of Obstetrics & Gynecology.
Depression, which occurs in about 12.7 percent of pregnant women, can cause problems for mothers and babies, including pre-term delivery, preeclampsia, sleep disturbances and disrupted mother-infant bonding.
It’s important for physicians to know how to identify depression in pregnant women, said the study authors, who noted that not all women who test positive on depression screening tests have or will develop clinical depression.
“We are hoping that [health-care] providers can use the presence or absence of risk factors such as those identified in our study to enhance their assessments for depression in addition to the information they obtain from the screening test,” study author Dr. Christie A. Lancaster, a clinical lecturer in the obstetrics and gynecology department at U-M, said in a news release.
- Antidepressants During Pregnancy Tied to Children’s Health
Babies whose mothers used antidepressants during pregnancy visit the doctor more often and have higher risks of certain health problems than other children their age, a new study suggests.
The study looked at the medical records of nearly 39,000 Norwegian children through the first year of life. It found that rates of congenital heart defects and physical therapy — a potential sign of movement-related problems — were elevated among babies whose mothers used antidepressants throughout pregnancy.
These children also tended to have more doctor visits and higher rates of certain other health problems, like respiratory and digestive symptoms. However, those rates were also elevated among children whose mothers had stopped using antidepressants before pregnancy.
This raises the possibility that the risks were related to the mother’s depression itself, rather than antidepressant use, according to the researchers, led by Dr. Tessa Ververs of the University Medical Center Utrecht in the Netherlands.
The bottom line for women on the medications is that the decision to continue or stop during pregnancy is an individual one. Women should talk with their doctor about what is best for them, Ververs told Reuters Health in an email.
Initial studies on the drugs’ safety were “reassuring,” Ververs and her colleagues note, but some recent reports have linked the medications to problems in newborns — including cases of congenital heart defects.
Antidepressant use in the third trimester has also been connected to higher risks of respiratory distress, feeding problems and irritability in newborns, the researchers note in their report published in the British obstetrics journal BJOG.
Of the 38,602 babies in the current study, 197 were born to mothers who used antidepressant throughout pregnancy. Another 820 mothers had stopped using the medications before pregnancy, while 543 used them only at certain points during pregnancy. Most women on medication during pregnancy — 71 percent — used a selective serotonin reuptake inhibitor (SSRI) such as paroxetine (Paxil) or fluoxetine (Prozac).
Ververs and her colleagues found that of the children whose mothers had used antidepressants throughout pregnancy, three had to have a major heart procedure performed in their first year of life. That made them six times more likely than children whose mothers had never used antidepressants to need a heart procedure.
The risk was not elevated among children whose mothers had stopped taking antidepressants.
When it came to doctor visits during the first year of life, both children whose mothers had continued to use antidepressants and those whose mothers had stopped tended to see the doctor more often than children whose mothers had never taken antidepressants. Similarly, both groups of children had higher rates of antibiotic use and respiratory or intestinal symptoms.
It’s possible that mothers’ depression itself was a factor here, according to Ververs’ team. Past studies have found that depressed mothers tend to take their children to the doctor more often than other mothers do.
Compared with other mothers, Ververs and her colleagues note, depressed moms may find it more difficult to cope with problems like respiratory ills and digestive symptoms.
More studies, the researchers write, are needed to tease apart the relationships between mothers’ mental health, medication use and specific health problems in infants.
For now, they say, the evidence does support fetal screening for heart defects when mothers continue to use antidepressants during pregnancy.
