When it comes to pregnancy, everyone is a vocal and nosy expert.
“My word! You can’t have WINE when you’re expecting!”
“Are you sure you should be eating that? It’s bad for the baby!”
“Oh, let me rub your beautiful baby bump. Yes, isn’t that nice?”
NOT! Source: someecards.com
Thus, I’m reluctant to enter the already tense conversation about what expectant mothers should do with their bodies. So my thoughts in this post are not directed at pregnant women (since they already have enough to deal with), but at professionals in the medical system. We’re now discovering ways that substances once thought to be harmless (like Bisphenol A and phthalates) affect the developing child. In this vein, I started researching antidepressants, and became increasingly worried the more I learned.
While widely prescribed to pregnant women, there are gaps in our knowledge about how antidepressants affect the growing fetus. These gaps contribute to my growing concern about the cavalier attitude taken by the medical establishment towards antidepressant use during pregnancy.
The Rise of Antidepressants
Antidepressants are one of the most commonly used medications in America today. The Centers for Disease Control estimates that 11% of Americans aged 12 or older take antidepressants. Over half have taken them for 2 years or longer. Since 1988, antidepressant use has increased by 400% across all age groups.
Although incidences of depression have been consistently on the rise in the past decades, part of this increase likely stems from better awareness and treatment of depression in that time frame. Better treatment is also available as more therapies and antidepressants have come on the market. Antidepressants are a primary way to treat depression. So their increased usage makes sense. What troubles me is another fact reported by the CDC:
“Less than one-third of Americans taking one antidepressant medication and less than one-half of those taking multiple antidepressants have seen a mental health professional in the past year.”
Doctors may be doing a better job of diagnosing depression, but follow up treatment for patients taking antidepressants is very poor. Taking medications for long time periods without medical checkups can be problematic, because of the potential for dependency, increased tolerance, and exacerbated side effects. These problems can be especially concerning when they coincide with pregnancy.
Pregnancy and antidepressants
Physiologically, pregnancy is a unique time for both mothers and children. Expectant mothers undergo vast hormonal, cardiovascular, metabolic, and weight changes. During pregnancy, the developing fetus grows from a tiny mass of cells into a human. There are critical stages of development, during which different parts of human physiology (e.g. the nervous system) are formed. During these critical stages, the developing fetus is especially vulnerable to toxins, like alcohol or (as we found out recently) Accutane. Unfortunately, the years of greatest fertility are also some of the most likely times to battle depression. About 1 in 8 pregnant women take antidepressants for some or all of their pregnancy.
Based on our current knowledge, antidepressant use during pregnancy has been linked to multiple health issues. Antidepressants exposure during development is associated with various negative neurodevelopmental outcomes (e.g. lower IQ, ADHD, autism, and developmental delays), although these findings have not been consistently replicated. SSRI (specific serotonin re-uptake inhibitors) use was also linked to higher odds of preterm birth, induced births, and Caesarian sections, as well as babies that are smaller than usual. Taking Paxil or tricyclin antidepressants during pregnancy is associated with higher odds of certain congenital heart conditions.
The risk of all these conditions is fairly low, especially when weighed against a relapse of depression (which may harm the baby through depressive episodes, smoking, drinking, or other unhealthy decisions). However, many of these outcomes either occur during birthing or are noticed at birth, and most of the studies focused on early life; only one study included children who were up to 17 years, and the other studies ended (at the latest) by age 9.
What about latent conditions that manifest in adolescence or adulthood? When those children age, will they be at higher risk for depression or suicide/self harm later in life? Or will they experience no negative effects?
The answer is: we don’t really know. Antidepressants have only been around since the 1950s. Their use took off in the late 1970s and early 1980s, and has been skyrocketing ever since. Drug development typically doesn’t utilize human studies that extend for years on end, as this could be prohibitively expensive.
However, as we’re learning now by studying BPA and other common exposures, long term and multigenerational studies are key to understanding negative effects that manifest after exposure in the womb.
These effects are tied to the critical stages of fetal development by the mechanism of epigenetics.
Tune in next week to see how epigenetics may help us understand how antidepressants affect the developing child!
Disclaimer: I do NOT think that women should be blamed or targeted for taking antidepressants during pregnancy. Antidepressants are absolutely necessary for many people to be mentally and physically healthy individuals. I am pointing out that there may be unappreciated health consequences to antidepressant use during pregnancy, and that these should be part of the conversation.
References
Hidaka, Brandon H. “Depression as a disease of modernity: explanations for increasing prevalence.” Journal of affective disorders 140.3 (2012): 205-214. DOI
El Marroun, Hanan, et al. “Maternal use of antidepressant or anxiolytic medication during pregnancy and childhood neurodevelopmental outcomes: a systematic review.” European child & adolescent psychiatry (2014): 1-20. DOI
Harrington, Rebecca A., et al. “Prenatal SSRI use and offspring with autism spectrum disorder or developmental delay.” Pediatrics 133.5 (2014): e1241-e1248. DOI
Lattimore, Keri A., et al. “Selective serotonin reuptake inhibitor (SSRI) use during pregnancy and effects on the fetus and newborn: a meta-analysis.”Journal of Perinatology 25.9 (2005): 595-604. DOI
Huang, Hsiang, et al. “A meta-analysis of the relationship between antidepressant use in pregnancy and the risk of preterm birth and low birth weight.” General hospital psychiatry 36.1 (2014): 13-18. DOI
Reis, Margareta, and Bengt Källén. “Delivery outcome after maternal use of antidepressant drugs in pregnancy: an update using Swedish data.”Psychological medicine 40.10 (2010): 1723-1733. DOI
Jensen, Hans Mørch, et al. “The effects of maternal depression and use of antidepressants during pregnancy on risk of a child small for gestational age.”Psychopharmacology 228.2 (2013): 199-205. DOI
Cohen, Lee S., et al. “Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment.” Jama 295.5 (2006): 499-507. DOI
Dolinoy, Dana C., Jennifer R. Weidman, and Randy L. Jirtle. “Epigenetic gene regulation: linking early developmental environment to adult disease.”Reproductive Toxicology 23.3 (2007): 297-307. DOI
Perera, Frederica, and Julie Herbstman. “Prenatal environmental exposures, epigenetics, and disease.” Reproductive toxicology 31.3 (2011): 363-373. DOI