Pregnancy and Antidepressant Therapy
By: Rupali Chadha-Flynn, MD • Posted on May 07, 2018 • Updated March 20, 2019
Depression in Women
Thankfully, the stigma around mental health has been rapidly decreasing. Mental health and wellness are important for everyone, and especially for expectant moms! Not everyone who is not mentally well is mentally ill so to speak. However, depression is a serious and common medical condition that can affect women of all ages, including during pregnancy.
Depression affects women more commonly than men and is most common in women with young children. Just like a fever, which can be caused by an infection, inflammation or even cancer, depression can have many causes. Some depression can be the result of the following:
- Life event
- Substance use
- Other environmental factors like an eating disorder, which can alter the brain
- Genetic change in the brain itself
- Hormone or vitamin deficiency
In any case, most depression is what doctors call “multifactorial,” which is just a fancy word for saying any or all of the above can interplay to create a depression.
When Does Depression Require Medical Attention and Treatment?
When does a depression go to Depression, or what I call, the big D? When does it require medicine? And what on earth do we do as women if we are pregnant, trying to get pregnant, or surprised to find out we are pregnant?
Depression often requires medical attention and treatment when it is a sustained low mood with loss of interest and pleasure in all activities with or without thoughts of suicide. Therapy is amazing when done in the right setting with a well-trained practitioner, but if one has total loss of pleasure, meaning even things like your favorite foods, your kids and sex are all blah, it is time for medicine. The pleasure centers and happy chemicals are all in their off positions and something is needed to turn it all back on.
Pregnancy and Depression
So what happens when we find out we are pregnant?
Firstly, a team approach is key.
Your psychiatrist (and yes, you should get yourself an MD or DO psychiatrist), your primary care doctor, your OB-GYN (physician or midwife) and your new pediatrician (or a family physician who may be taking care of you and your child) all need to work together as a team. They should all know the plan and what medications and at what doses they are being prescribed.
Secondly, when do you decide to stay on medicine versus stopping it?
In each person, the risks of Depression must be weighed against the risk of the medicine.
What are the risks of a depressed mom-to-be?
- You may not eat well
- Take your prenatal vitamins
- Make your appointments
- Sustain a healthy, good environment for baby because of your illness.
Depression is a monster. It can take the best mom and make it so hard for them to parent.
What are the risks of taking antidepressant medicines while pregnant?
In the United States, eight percent of pregnant women take antidepressants and the majority of these medications are SSRIs (Selective Serotonin Reuptake Inhibitors). These include medicines like:
- Zoloft (sertraline)
- Prozac (fluoxetine)
- Celexa (citalopram)
- Lexapro (escitaloprma)
- Luvox (fluvoxamine)
Paxil (paroxetine) is also an SSRI, but there are reports of congenital heart defects in the baby and so PAXIL/PAROXETINE SHOULD BE avoided.
However, the rest of the SSRIs are considered safer. The risks, though small, are there and are usually preterm birth (meaning baby is born a little earlier) and a risk of post-partum bleeding to mom. There is not much increase in the risk of miscarriage or hypertensive disorders in pregnancy, such as preeclampsia.
The other two major classes of antidepressants are SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors) and atypicals. SNRIs like Effexor (venlafaxine) and Cymbalta (duloxetine) are like SSRIs, but also increase the risk of hypertensive disorders in pregnancy such as preeclampsia.
Atypicals, which include Wellbutrin (bupropropion), can increase the risk of miscarriages, but do not increase the risk of hypertensive disorders in pregnancy (such as preeclampsia) or post-delivery bleeding (postpartum hemorrhage). Older antidepressants have other risks and this should be discussed with one’s psychiatrist, primary care doctor and OB-GYN.
What to Discuss With your Pediatrician
Involving a pediatrician is as important as SSRIs, which are most commonly used, but can have some issues for baby once delivered. Before delivery, as mentioned, there is a low risk of congenital defects (greatest with Paxil/paroxetine), preterm birth, low birth weight and pregnancy complications, but afterwards there are some things to look out for as well.
Poor Neonatal Adaption
Poor Neonatal Adaption occurs when baby is exposed to SSRIs or SNRIs in the third trimester. Some feel it may be serotonin withdrawal while some hypothesize it is serotonin toxicity. Either way it usually only lasts two weeks to a month and then there is usually no enduring effect. Symptoms include:
- inconsolable crying
- poor sleep
- poor feeding with diarrhea or vomiting
- low blood sugar
- low body temperatures
- difficulty breathing
- rarely seizures
Severe cases need medical intervention. Doctors do no recommend lowering mom's dose of antidepressants before delivery as it does not change or help this syndrome, and mom’s risk of relapse to depression is the highest right after delivery!
Persistent Pulmonary Hypertension of the Newborn
Persistent Pulmonary Hypertension of the Newborn is a serious, potentially fatal condition, but only happens in 2 per 1,000 live births.
There is some controversy that the use of antidepressants causes some long terms effects in growth, intelligence, language and motor skills or in the development of psychiatric disorders as the child grows. The actual science and studies are very limited.
New Treatment for Postpartum Depression
On March 19, 2019, the FDA approved Zulresso (brexanolone), a new drug in the management of Postpartum Depression. This drug’s mechanism of action is nothing like what is currently available on the market. Whereas current antidepressants (mostly SSRIs are used) are helpful only after taking them for a few weeks to months, Zulresso works immediately following a 60-hour infusion. Since it is administered intravenously (and yes over 60 hours), it must be done as an inpatient or at an infusion center in a monitored bed. The mother must be closely observed for loss of consciousness or excessive sedation. Interactions with her children are also to be monitored, as a result while receiving this infusion.
Whereas current antidepressants work on serotonin, norepinephrine and dopamine receptors, Zulresso works what is called a GABA-A receptor. The cost for the drug is high - $34,000 plus the cost of staying in a hospital and doctor’s fees. But for a mother who is severely depressed, especially if she is hospitalized already, a recovery in two and a half days is better for her and bonding with her infant rather than waiting 3-4 weeks to months for relief. This drug was just released and all three studies that allowed its approval were shorter in term, so long-term side effects are not yet known. The drug’s most common side effects were:
It may be safe in breast-feeding mothers. For now, most psychiatric physicians will likely use this in severely depressed moms, especially in those with thoughts of self-harm and/or wishing to harm their infant.
Depression can be a life threatening and grossly debilitating illness. If you have Depression or develop it, dealing with it requires a team. Not just of your doctors, but of your family, friends, and all the supporters you trust. Seek the care of an MD or DO psychiatrist early! Have him or her link with your primary care doctor and all the doctors on your team. Sometimes antidepressants are necessary and are a better, safer option for you. Only you and your doctor can decide!
Be Strong, Be Healthy, Be in Charge!
- General and Forensic Psychiatrist
- Training: The Johns Hopkins Hospital (medicine internship, psych residency)
- UCLA (forensics)
- Directs a Women’s Unit and is a Forensic Expert/Medical Examiner
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