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October 6, 2009

Depression Is a Dilemma for Women in Pregnancy


When Sherean Malekzadeh Allen of Marietta, Ga., learned she was pregnant, she was 43, had been married for two years, had gone through two miscarriages and had all but given up hope of having a baby.

But instead of being overjoyed, Ms. Allen was immobilized: panic-ridden, nauseated, listless and thoroughly depressed. She could not rouse herself to go to work in the marketing business she founded and ran, or even get through the newspaper.

And she faced the pregnant woman’s quintessential dilemma: take drugs that might pose a risk to the developing baby, or struggle through an anguishing pregnancy that could harm the baby in other ways?

“Every single thing you put in your body when you’re pregnant, you wonder, ‘Oh, my God, am I growing my baby an extra finger?’ ” Ms. Allen said. “I was worried that I would hurt the baby if I took the pills, and I was worried I would hurt the baby if I didn’t.”

As many as a quarter of all pregnant women suffer from depression, and about an eighth use an antidepressant at some time during pregnancy, according to 2003 figures. Although many antidepressants appear to be fairly safe, studies have reported links between maternal use and a small increased risk of some fetal malformations. Other potential problems for the newborn include drug withdrawal and persistent pulmonary hypertension, which can impair blood flow to the lungs.

Recently, a Danish study in the British medical journal BMJ reported a link between pregnant women’s use of several antidepressants in the S.S.R.I. class, including Celexa and Zoloft, and an increased risk for a common heart defect in babies.

And a paper that appears Tuesday in The Archives of Pediatrics & Adolescent Medicine reports that babies born to mothers who use S.S.R.I. drugs were more likely to have low scores on the five-minute Apgar test, an overall measure of newborn health, and to be admitted to the neonatal intensive care unit.

To put such findings in perspective, experts from the American Psychiatric Association and the American College of Obstetricians and Gynecologists joined forces to review existing data and make recommendations for managing depression during pregnancy.

Their report, published in the September-October issue of General Hospital Psychiatry, finds that talk therapy should be the first-line treatment for mild to moderate depression, but it says that for severe cases the risks of antidepressants and even shock therapy are relatively low. Its main message, however, is that no generalizations apply: treatment decisions should be made case by case.

“There’s not a one-size-fits-all answer,” said Dr. Kimberly Yonkers, a professor of psychiatry and obstetrics and gynecology at Yale School of Medicine who was the report’s lead author, and who acknowledged receiving research support from antidepressant manufacturers. “You can’t say, ‘Stop medication for all women because it’s harmful,’ and you can’t put all women on medication either.”

The tone of the report is generally reassuring but is filled with caveats. Because pregnant women are rarely recruited for clinical trials, research on drug effects during pregnancy is limited; there is no data from the kind of randomized controlled trials that scientists trust most. Much of the information comes from large epidemiological studies, many in Europe, that link patient databases; the analyses often cannot weed out or control for characteristics other than drugs that may be affecting the pregnancies.

The new report — whose nine authors included four experts who acknowledged some financial, research or other ties to drug companies — goes to great lengths to point out the inconsistencies in the findings about some of the more alarming drug associations.

It is also hard to weigh the risks of medication against those of an untreated depression. Studies have linked depression during pregnancy to premature births, growth changes, and irritability and inattention in the baby after birth. (Prenatal use of antidepressants has also been linked with premature birth, low birth weight and miscarriages.)

“Women have been having babies and taking these medications now for decades, and so far nothing striking has shown up,” said Dr. Nada Stotland, a recent president of the American Psychiatric Association.

Still, Dr. Stotland and other experts suggested that women who had a history of depression or were taking medication might want to consult a doctor before becoming pregnant rather than quit the drug on their own, which would put them at risk of a relapse.

In 2005, the Food and Drug Administration classified paroxetine, sold as Paxil, as a drug to be avoided during pregnancy after studies linked its use in the first trimester to an increased risk of heart defects in babies. The new paper says the agency based its action on data that were “not strong,” but a number of studies have since found similar associations.

The Danish study reported that babies born to mothers who took Celexa (citalopram) and Zoloft (sertraline) were at double the risk of having septal heart defects, so-called holes in the heart. The absolute risk is still small, less than 1 percent, and the holes often close on their own. But the study noted that the risk was even higher if the mother took more than one kind of S.S.R.I. during her pregnancy.

Use of the same class of drugs late in pregnancy has been linked to an increased risk for persistent pulmonary hypertension, which can cause respiratory problems and serious complications in newborns. One recent study reported a sixfold increase in risk for the condition among babies born to mothers who used S.S.R.I.’s during the second half of pregnancy. But even with the use of drugs, the condition affects no more than 1.2 percent of babies, the report said.

A greater number of babies are affected by symptoms of drug withdrawal after birth: 15 to 30 percent of babies whose mothers used S.S.R.I.’s in late pregnancy experience effects like irritability, weak crying or no crying, abnormally fast breathing, hypoglycemia, unstable temperature and seizure. The symptoms usually resolve within two weeks.

Some critics said the paper gave short shrift to nondrug approaches like homeopathic remedies and nutritional supplements, while other experts said the paper’s endorsement of psychotherapy was “politically correct” but ultimately unrealistic.

Dr. Shari I. Lusskin, director of reproductive psychiatry at N.Y.U. Langone Medical Center, said the real danger was undertreatment. “By the time I get to hear about somebody’s perinatal depression,” Dr. Lusskin said, “it’s usually worse than what can be treated with psychotherapy alone, because women go out of their way not to complain; they don’t want to be put on medication, and they feel guilty.

“We should use a low threshold for treating women aggressively.”

Ms. Allen, of Marietta, said she needed aggressive treatment, so she decided to take medication — but was anxious about every pill. “I would wait six or seven hours before taking the pill, and just work myself up into more of a state,” she recalled. “My husband would say, ‘That’s not good for the baby; don’t do that.’ ”

Her son, Hunter Jamison Allen, was born at 9:05 p.m. on Election Day 2008, weighing 6 pounds 13 ounces, and scoring perfect Apgars. “He’s happy, healthy and adorable,” Ms. Allen said. “He’s my puddin’ pop.”


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