Thursday, February 15, 2007

Ask a Scientist: Antidepressants and Pregnancy (6)

Series: Antidepressants, Pregnancy, Risks
  • Introduction
  1. Spontaneous abortion
  2. Premature birth
  3. Congenital or teratogenic defects; that is, malformations in utero
    • Cardiac defects
  4. Antenatal/ postnatal adaptation problems
    • Muscle stiffness
    • Breathing distress at birth
    • Neurological withdrawal symptoms
  5. Breastfeeding risks
    • Infant weight gain
    • Infant serotonin levels
    • Long-term neurologic development
  6. Maternal risks of going without treatment
    • Relapses
    • Infant failure to thrive
    • Parenting problems, attachment, child behavior
This information is drawn from published articles in medical journals, some of which are compiled here, and from public databases. (See also: summaries on Motherisk, FDA registries for pregnant women, this excellent Medscape article, and the FDA's index by drug name.) Information is also available through PubMed by searching various terms; I suggest starting with 'antidepressants and pregnancy'.

A list of generic and trade names is here.

By the way, the pregnancy-and questions currently outnumber all others about ten to one. Who'd have guessed? Women are curious and underinformed!

6. Maternal risks and consequences of untreated depression

Aside from the obvious things about not being treated for depression (during or after pregnancy)- like not eating right, and never managing to wash the dishes, and being completely unable to take joy in anything, for example- it appears that being depressed affects children's growth and development. I find this entirely unsurprising: interaction with children, including how many words one speaks to them, has a huge impact on their development. (Here is where I would put references to 200 studies about this, if I had time.)

[Here is where I repeat that this is not medical advice, okay? These are my personal opinions.]

Each woman (possibly with her partner) decides what risks she is willing to take in pregnancy, and I'm all for that; the reason I wanted to write this is because so many doctors refuse to treat depression in pregnancy without evaluating the risks or letting the patient decide, and this in a situation where the risks appear to be relatively low (as opposed to, say, isoretinoin, which is associated with a roughly 25% incidence of major birth defects and a high rate of SA).

But especially once one is postpartum, I would argue there is NO reason to leave depression untreated. It is neither ennobling nor noble. It is merely dreadful.

And by the way, I have eliminated from consideration all studies that claim vitamins/ fish oil/ acupuncture will make all MDD patients, and especially women, feel all better. Because I don't do quackery. It exhausts me.

6a. Relapses

Relapses are very common in depression; one study, done over 1.5 years, cites a 40% relapse rate in the control group. They are investigating only one drug, but even in this isolated case, treatment reduces relapses to 26% and increases the time to relapse.
Another study cites a recurrence rate of 65% in controls vs. 27% treated with the same one drug. [And boy, are those control figures, um, depressing, by the way.]

These studies are both in cohorts with MDD. If you have MDD and it's untreated, guess what? It'll probably come back!

A series of small studies in pregnant women found that while half stopped or tried to stop taking ADs while pregnant, 75% of MDD patients "experienced depressive relapse". Of patients who discontinued or decreased AD dose, 61% went back to taking them.

6b. Infant failure to thrive
As previously mentioned, one study comparing 5 SSRIs and venlafaxine shows that maternal depression of >2 months decreases infant weight gain. This is confirmed by other studies, one longitudinal one which finds that 'infants of prenatally depressed mothers showed significantly more growth retardation than controls at all time points.'

A review mentions that extensive evidence shows that persistent deprssion is associated with higher cortisol levels and lower serotonin, and these stress effects are echoed in the infant's 'biochemical profile'. They also mention that prenatal depression is associated with both physical and behavioral complications throughout pregnancy, birth, and infancy. These results are supported by animal studies showing that maternal stress affects pregnancy outcome and offspring development.

To further sweeten the pot, an assortment of studies find that maternal depression and/or other psychiatric conditions are associated with missing prenatal checkups, prematurity, low birth rate, and more NICU stays: i.e., poorer self-and-fetus care during pregnancy, and poorer outcomes in birth.

6c. Parenting problems, attachment, child behavior

Here I'll quote because I couldn't put it any better:

"Depressive symptoms have also been found to be associated with negative parenting behaviors, insecure attachment, and subsequent internalizing behaviors in the child."

"Through children's early adolescence, maternal drug use [Ed: illegal, not prescription] is no more inimical for them than is maternal depression.... [on] mothers' everyday functioning [:] results showed that negative parenting behaviors were linked with multiple adverse child outcomes."

Child difficulty [to the parents] was associated with elevated levels of psychosocial stress, but only for some participants. Parental psychopathological symptoms during pregnancy should thus be considered as a risk factor for elevated and prolonged depression and elevated psychosocial stress in mothers and fathers across the transition to parenthood." So if you're stressed and depressed, your child may be even more of a handful. Eeeek.

"If depression persists into the postpartum period, it can have long-term consequences for both mother and baby. Mothers might go on to develop chronic mood disorders, and untreated postpartum depression can impair mother-infant attachment (level I evidence). Finally, being exposed to a chronically depressed mother can have cognitive, emotional, and behavioural consequences for a child."


  • Depression is miserable and loathsome.
  • Untreated depression in pregnancy is associated with higher risk of poor outcomes.
  • Infants with depressed mothers have weight-gain delays.
  • Untreated depression after pregnancy is associated with developmental troubles and poor parenting.
  • Parental depression interferes with children's physical and emotional development.
Cheers, and thanks for reading to the end of this exhaustingly long series. Whoooo.