Taking common antidepressants during pregnancy doesn't increase a
woman's risk of having a stillbirth, according to a new study of over
one million Nordic women.
The drugs, known as selective serotonin reuptake inhibitors, or SSRIs, include fluoxetine (marketed as Prozac) and citalopram (Celexa).
Earlier studies have tied SSRIs to a slightly higher rate of some kinds of birth defects and newborn lung problems. But whether the drugs also raise a woman's chance of stillbirth - when the fetus dies in the uterus after at least 20 weeks of pregnancy - has been unclear.
"Studies previously have not really been large enough to answer this question," said Dr. Olof Stephansson, the lead author of the new report from the Karolinska Institute in Stockholm.
"From our study, we don't find any reason to stop taking your medication, because untreated depression may be harmful for the pregnancy and the baby," he told Reuters Health.
Stephansson and his colleagues consulted prescription drug registries and birth records from Denmark, Finland, Iceland, Norway and Sweden, including more than 1.6 million births between 1996 and 2007. Just over 29,000 of the mothers, or close to two percent, had filled a prescription for an antidepressant during their pregnancy.
Overall, between three and four of every 1,000 births was a stillbirth, the research team reported this week in the Journal of the American Medical Association.
In addition, about two of every 1,000 babies died within four weeks of being born and one in 1,000 died between one and 12 months of age.
Antidepressant use at any time during pregnancy was initially tied to a slightly higher risk of stillbirth. But when Stephansson and his colleagues took into account women's general health, age and whether they smoked, any effect of the drugs disappeared.
Moms-to-be who were on SSRIs tended to be older and were more likely to smoke and have diabetes and high blood pressure than those who weren't taking antidepressants, Stephansson said.
There was still a slightly higher chance of stillbirth among women who took the drugs very early in their pregnancies - the time when a fetus is thought to be most vulnerable to its mother's medications and environmental exposures. But because less than 100 women fit into that category and had a stillbirth the finding "should be interpreted with caution," the researchers said.
Blaming pregnancy complications on any specific drug is always a challenge, according to one researcher not involved in the new study.
"It's difficult and under most circumstances impossible to separate the effects of SSRIs and depression itself or the lifestyle associated with depression," said Dr. Richard Shelton, a psychiatrist who has studied antidepressant use in pregnancy at the University of Alabama at Birmingham.
For example, even when women's general health and behavior are accounted for, they might not mention drinking and illegal drug use - which can be tied to both depression and pregnancy complications.
But so far, the evidence suggests the effects of antidepressant use
during pregnancy are "pretty neutral," Shelton told Reuters Health.
Researchers: If you need them, take them
Women who are taking antidepressants and planning a pregnancy should talk with both their obstetrician and psychiatrist to figure out what will be safest for them and their baby, Stephansson said.
But the bottom line, he added, is that "you should stick to the lowest dose possible and not stop with the medication if you need it."
"The general recommendation is if a woman can be off an antidepressant medication during pregnancy, that's probably a good idea. I think that's probably a good idea for any kind of medication," said Shelton, because all drugs may have small, unknown risks.
"But if a woman is depressed enough to warrant treatment, then treatment is probably reasonable," he added. That can mean antidepressants or other options such as talk therapy.
Shelton said women should also seek treatment for other health and lifestyle issues tied to depression, such as being overweight and smoking, preferably before getting pregnant.
The drugs, known as selective serotonin reuptake inhibitors, or SSRIs, include fluoxetine (marketed as Prozac) and citalopram (Celexa).
Earlier studies have tied SSRIs to a slightly higher rate of some kinds of birth defects and newborn lung problems. But whether the drugs also raise a woman's chance of stillbirth - when the fetus dies in the uterus after at least 20 weeks of pregnancy - has been unclear.
"Studies previously have not really been large enough to answer this question," said Dr. Olof Stephansson, the lead author of the new report from the Karolinska Institute in Stockholm.
"From our study, we don't find any reason to stop taking your medication, because untreated depression may be harmful for the pregnancy and the baby," he told Reuters Health.
Stephansson and his colleagues consulted prescription drug registries and birth records from Denmark, Finland, Iceland, Norway and Sweden, including more than 1.6 million births between 1996 and 2007. Just over 29,000 of the mothers, or close to two percent, had filled a prescription for an antidepressant during their pregnancy.
Overall, between three and four of every 1,000 births was a stillbirth, the research team reported this week in the Journal of the American Medical Association.
In addition, about two of every 1,000 babies died within four weeks of being born and one in 1,000 died between one and 12 months of age.
Antidepressant use at any time during pregnancy was initially tied to a slightly higher risk of stillbirth. But when Stephansson and his colleagues took into account women's general health, age and whether they smoked, any effect of the drugs disappeared.
Moms-to-be who were on SSRIs tended to be older and were more likely to smoke and have diabetes and high blood pressure than those who weren't taking antidepressants, Stephansson said.
There was still a slightly higher chance of stillbirth among women who took the drugs very early in their pregnancies - the time when a fetus is thought to be most vulnerable to its mother's medications and environmental exposures. But because less than 100 women fit into that category and had a stillbirth the finding "should be interpreted with caution," the researchers said.
Blaming pregnancy complications on any specific drug is always a challenge, according to one researcher not involved in the new study.
"It's difficult and under most circumstances impossible to separate the effects of SSRIs and depression itself or the lifestyle associated with depression," said Dr. Richard Shelton, a psychiatrist who has studied antidepressant use in pregnancy at the University of Alabama at Birmingham.
For example, even when women's general health and behavior are accounted for, they might not mention drinking and illegal drug use - which can be tied to both depression and pregnancy complications.
But so far, the evidence suggests the effects of antidepressant use
during pregnancy are "pretty neutral," Shelton told Reuters Health.Researchers: If you need them, take them
Women who are taking antidepressants and planning a pregnancy should talk with both their obstetrician and psychiatrist to figure out what will be safest for them and their baby, Stephansson said.
But the bottom line, he added, is that "you should stick to the lowest dose possible and not stop with the medication if you need it."
"The general recommendation is if a woman can be off an antidepressant medication during pregnancy, that's probably a good idea. I think that's probably a good idea for any kind of medication," said Shelton, because all drugs may have small, unknown risks.
"But if a woman is depressed enough to warrant treatment, then treatment is probably reasonable," he added. That can mean antidepressants or other options such as talk therapy.
Shelton said women should also seek treatment for other health and lifestyle issues tied to depression, such as being overweight and smoking, preferably before getting pregnant.
Jan. 1, 2013 -- Antidepressant use during pregnancy, long debated for its safety, is linked with a higher overall risk of stillbirth and newborn death. Now, a new study shows that risk may not be warranted.
"After taking maternal characteristics such as smoking and maternal age into account, as well as previous hospitalization for psychiatric disease ... there was no association between SSRI (antidepressants) and stillbirth and infant [death]," says researcher Olof Stephansson, MD, PhD, of the Karolinksa Institutet in Stockholm.
The Swedish study included more than 1.6 million births in five Nordic countries. Nearly 30,000 of the women had filled a prescription for an SSRI (selective serotonin reuptake inhibitor) during pregnancy.
But a U.S.-based expert has some concerns about the study.
"This study looked at information on dispensed drugs, not ingested drugs, and these numbers are often quite different," says Adam Urato, MD, assistant professor of obstetrics and gynecology at Tufts University School of Medicine.
That could result in inaccurate findings, he says. "I don't find the study results particularly reassuring," he says.
Up to 19% of pregnant women have depression during pregnancy, according to the researchers. The depression itself is linked with ill effects, including an increased risk of early delivery, which in turn may cause harm to the newborn.
The new research was funded by the Swedish Pharmacy Company.
The study is published in the Journal of the American Medical Association.
Antidepressants During Pregnancy: Study Details
Previous research about SSRI use during pregnancy has suggested it may be linked with an increased risk of prematurity, stillbirths, and birth defects. Some studies show an increased risk of miscarriage and other problems.
The three areas the researchers focused on were stillbirths and newborn and infant deaths. The researchers compared the birth outcomes for the women who took SSRIs and those who did not from 1996 through 2007. They got information on the use of SSRIs from prescription registries.
This type of antidepressant is the most-often prescribed for depression during pregnancy, the researchers say.
Overall, more than 6,000 babies were stillborn. More than 3,600 died as newborns, and another 1,578 died later, from ages 28 days old to 364 days old.
Women registered with an SSRI prescription had higher stillbirth rates -- 4.62 for every 1,000, compared to 3.69 per 1,000 for women who were not on the drugs.
Women registered with an SSRI prescription also had a higher risk of their infants dying at ages 28 days to just under a year.
The rates of early newborn death were similar between groups.
Next, the researchers took into account factors that could have played a role in stillbirths or infant deaths. These included the mother's age, cigarette smoking, and the severity of the mother's psychiatric disease.
When they took those risk factors into account, they found no substantial link between the antidepressant use and risks of stillbirth or death.
Even so, the researchers say women need to discuss SSRI use with their doctor to weigh the pros and cons. "Always discuss medication for depression with your obstetrician in early pregnancy for advice," Stephansson says.
The inexact information about who exactly took the SSRIs is a problem, Urato says. "When exposure information is inexact ... the result is often that we do not find evidence of harm from the drug," he says, although harm may exist.
A woman prescribed an SSRI who does not take it and then has a good birth outcome is classified as taking an SSRI, contributing to the finding of no harm, he says.
Urato points to other research, including links with SSRI use and miscarriage, birth defects, and other problems.
"Depressed pregnant women need good care and treatment, but medication is not the only option for treatment," he says.
In 2009, the American Psychiatric Association and the American College of Obstetricians and Gynecologists issued a joint report on treatment recommendations for depression during pregnancy. It suggests discussing the risks and benefits of antidepressants during pregnancy. It also suggests thatpsychotherapy may help women who prefer to avoid the drugs.
Scientists and doctors have not yet seemed to settle the facts of the matter. Antidepressants during pregnancy make some mothers and doctors nervous, and rightfully so. The most common type of antidepressants—SSRIs—have been linked to higher rates of a rare hypertension in newborns. This specific risk of antidepressants during pregnancy has motivated the FDA to warn that doctors and pregnant patients have to think very carefully before deciding whether or not antidepressants are appropriate.
Many clinicians feel, however, that the drugs should be used when the mother’s severity of depression makes treatment less risky than skipping the meds. After all, untreated depression during pregnancy can also have many bad results, such as low birth weight and even maternal suicide.
But what does the latest research on antidepressants and pregnancy say?
A recent study by scientists at the University of British Columbia has made a connection between depression, SSRI use, and language development in infants. The researchers found that SSRI use seemed to speed up early language development, while untreated depression seemed to slow it down.
Although accelerated development is normally cheered in today’s world, this is not necessarily a good thing. The primary issue at hand is the new connection between antidepressant use and language development. Scientists do not yet know why or how this connection is made, and they have yet to determine whether non-SSRI antidepressant drugs have similar effects.
Long-term effects of SSRIs on infant language development are not yet known, since the babies were only studied through 10 months of age. If this gap in development between babies of treated and untreated mothers disappears quickly, antidepressant use during pregnancy may have less potential to permanently impact a baby’s brain. If these differences remain, however, the ability of SSRIs to change infant development long-term should not be ignored.
Depression During Pregnancy
Maternal depression during pregnancy is a real concern. According to the American Pregnancy Association, as many as 14–23% of pregnant women experience symptoms of depression. If you are experiencing symptoms of depression during pregnancy, seek help. Together with a health professional, you can decide the best course of treatment for both you and your growing baby.
More research is needed to uncover the way SSRI and other antidepressant drugs can impact a baby’s health and development both inside and outside of the womb. If you are depressed and pregnant, do not stop taking antidepressants unless your doctor recommends it. Work closely with your doctor to weigh the potential pros and cons of antidepressant use during pregnancy.
